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Relation  of  Operating  and  Adjoining  Rooms. 


THE 


Operating  Room 


AND  THE 


Patient 


BY 
RUSSELL  S.  FOWLER,  M.D. 

SURGEON  TO   THE   GERMAN    HOSPITAL,    BROOKLYN,    NEW   YORK 


jfull^  miiistrateO 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS   COMPANY 

1906 


Copyright,   1906,  by  W.  B.   Saunders  Company 


PRINTED    IN    PHILADELPHIA. 


THIS  SMALL  VOLUME  IS  DEDICATED  TO  THE  INTERNES  AND  NURSES 
WHOM  I  HAVE  HELPED  TO  TRAIN,  AND  TO  THOSE  WHO  ARE  YET  TO  UNDER- 
GO TRAINING,  AS  A  FORERUNNER  TO  A  MUCH  LARGER  VOLUME  UPON 
POST-OPERATIVE      TREATMENT. 


PREFACE. 


I  wish  to  thank  Miss  Kurtz,  Supervisor  of  Nurses  at 
the  German  Hospital,  for  many  kind  suggestions  in  the 
chapters  upon  supplies;  Mr.  Francis  A.  Deck  for  his 
admirable  illustrating;  and  last,  but  not  least,  the  W. 
B.  Saunders  Company  for  the  excellent  manner  in  which 
they  have  brought  out  this  little  book. 

January  i,   1906,  Brooklyn,  299  De  Kalb  Avenue. 


CONTENTS. 


PAGE 

Chapter  I. — The  Operating  Room    and  its  Personnel ii 

General  considerations.  Arrangement  during  operation. 
Preparation  of  table.  Sinks.  Scrub-up  tray.  Disinfec- 
tion of  operating  room ;  table ;  nickel ;  brass ;  glass.  Per- 
,  sonnel.  Costumes:  nurses,  anesthetist,  orderly,  opera- 
tor and  assistants,  visitors.  Operating  room  nurse.  Jun- 
ior operating  room  nurse.  Anesthetic  nurse.  Prelimi- 
nary training   for   nurses.      Operating   room   orderly. 

Chapter  II. — The  Instrument  and  Supply  Room 23 

General  considerations.  Care  of  instruments.  Brushes. 
Soap.  Nail  cleaners.  Chlorinated  lime  and  sodium  car- 
bonate. Hand  lotions.  Caps.  Masks.  Rubber  aprons. 
Gowns.  Rubber  gloves.  Finger  cots.  Protectors.  Lap- 
arotomy sheets.  Perineal  sheets.  Anus  protectors. 
Towels.  Blankets.  Screen  covers.  Rubber  sheeting. 
Kelly  pads.  Pad  covers.  Bottle  bags.  Hand  and  leg 
bags.  Powders.  Iodoform.  Zinc  oxid.  Saline  pow- 
ders. Potassium  permanganate.  Oxalic  acid.  Thiersch 
powders.  Boracic  acid.  Salicylic  acid.  Bichlorid  of 
mercury.  Bicarbonate  of  soda.  Sodium  chlorid.  Mag- 
nesia sulphate.  Bichromate  of  potash.  Cocaine  hydro- 
chlorate.  Solutions.  Bichloride  of  mercury.  Carbolic 
acid.  Boracic  acid.  Thiersch.  Normal  saline.  Bichlo- 
rid permanganate.  Permanganate  of  potassium.  Ox- 
alic acid.  Ammonia.  Lime  water.  Iodoform  emulsion. 
Chlorid  of  zinc.  Bichromate  of  potash.  Woelfier's. 
Tincture  of  iodin.  Benzin.  Alcohol.  Sterile  water. 
Hydrogen  peroxid.  Sodium  bicarbonate.  Commercial 
ether.  Glycerin.  Balsam  of  Peru.  Ichthyol.  Vase- 
lin.  Olive  oil.  Whale  oil  and  iodoform  mixture.  Par- 
affin.     Cocain. 

Chapter  III. — The  Instrument  and  Supply  Room  (continued)     36 
Gauzes.      Iodoform.      Zinc   oxid.      Boracic  acid.      Bichlo- 
rid of  mercury.     Thiersch.      Balsam  of  Peru.      Carbolized. 

5 


6  CONTENTS. 

PAGE 

Gauze  drains.  Wicking  drain.  Silk  protective  drains. 
Mikulicz  drain.  Cotton.  Lamb's  wool.  Sponges:  hand, 
stick,  laparotomy.  Compresses.  Laparotomy  pads. 
Laparotomy  dressing.  Paper  dressing.  Cleansing  of 
gauze.  Bandages.  Bandage  box.  Retractor  bandages. 
T-bandages.  Triangular  bandages.  Slings.  Breast  binder. 
Abdominal  binder.  Adhesive  plaster.  Waxed  paper. 
Paraffined  paper.  Rubber  goods.  Drainage  tubes. 
Rubber  dam.  Green  silk  protective.  Filiform  bougies. 
Tourniquet.  Rubber  bolsters.  Glass  goods.  Suture  and 
'  ligature  material.  Plain  catgut.  Chromic  catgut.  For- 
malin catgut.  Antiseptic  catgut.  lodin  catgut. 
Braided  catgut.  Kangaroo  tendon.  Silk.  Linen  thread. 
Paraffin  silk.  Silkworm-gut.  Horse  hair.  Silver  wire. 
Percentage  table.     Thermo-cautery.      Sand  bags.     Splints. 

Chapter  IV. — Anesthesia '. 54 

Anesthetic  room.  Anesthetic  cart.  Oxygen  apparatus. 
Anesthetic  tray.  Restoratives.  Ether  inhaler.  The 
Anesthetist.  Selection  of  the  anesthetic.  Ether  anes- 
thesia. Chloroform  anesthesia.  Ethyl  bromid.  Nit- 
rous oxid  anesthesia.  Junker's  apparatus.  Trendelen- 
burg cannula.  Anesthol.  Spinal  analgesia.  Cocain 
anesthesia. 


Chapter  V.- — The  Patient 76 

General  preparation.  The  blood,  heart,  lungs,  and  kid- 
neys. The  skin.  The  bowels.  Diet.  Local  prepara- 
tion. General  directions.  Head.  Mouth.  Neck.  Tho- 
rax. Abdomen.  Genitals.  Rectum  and  anus.  Ex- 
tremities. Nose  and  pharynx.  Esophagus  and  stomach. 
Small  and  large  intestine.  Urinary  system.  Prepara- 
tion just  previous  to  anesthetization.  Position  of  the  pa- 
tient. Dependent  head  position.  Extended  neck  posi- 
tion. Position  for  amputation  of  breast.  Position  for 
thoracotomy.  Position  for  operations  upon  the  upper 
abdomen.  Dorsal  position.  Trendelenburg  position. 
Reversed  Trendelenburg  position.  Lithotomy  position. 
Exaggerated  lithotomy  position.  Sims'  position.  Kidney 
position.  Ventral  position.  Knee  chest  position.  Hand 
disinfection.      Application  of  dressings. 

Chapter  VL — ^General  Considerations  in  the  After-treat- 
ment      102 

General  considerations.      Purpose.      Bed.      Position.      Bed 


CONTENTS.  7 

PAGE 

rest.  Recovery  from  anesthesia.  Anesthetic  vomiting. 
Treatment.  Character  of  vomit.  Persistent  vomiting. 
General  appearance  of  patient.  Uncomphcated  cases. 
Distention.  Hemorrhage.  Peritonitis.  Pneumonia. 
Parotitis.  Pain.  Thirst.         Nutrition.  Digestion. 

Fecal  impaction.  Dilatation  of  the  stomach.  General 
rules  of  hygiene.  Urine.  Albuminuria.  Cystitis.  An- 
uria. Retention  of  Urine.  Catheterization  in  the  female. 
Temperature.  Auto-intoxication.  Aseptic  fever.  Nor- 
mal wound  temperature.  Infection  of  the  deeper  tissues. 
Pulse.     Respiration. 

Chapter    VII. — Lists    of    Instruments    and    Dressing    Com- 
monly Employed 119 

Index 161 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

Relation  of  operating  room  and  adjoining  rooms,  Frontispiece 

1 .  The  operating  room 12 

2.  Assistant's  costume 16 

3.  Nurse's  costume 16 

4.  The  instrument  and  supply  room,  first  view 24 

5.  Nail  cleaner 26 

6.  The  instrument  and  supply  room,  second  view 37 

7.  The  sterilizing  room 40 

8.  Dowd's  condenser 49 

9.  The  anesthetic  room 55 

10.  Author's  modification  of  G.   R.   Fowler's  ether  inhaler  ....  56 

11.  Junker's  apparatus 67 

12.  Trendelenburg   cannula 68 

13.  Dorsal  position,   operation  suit    82 

14.  Dependent  head  position ; 83 

15.  Extended  neck  position 83 

16.  Position  for  breast  amputation 84 

17.  Thoracotomy  position 85 

18.  Position  for  operations  upon  the  upper  abdomen 86 

19.  Dorsal  position 87 

20.  Trendelenburg  position 88 

21.  Reversed  Trendelenburg  position 89 

22.  Lithotomy  position,  with  sling  sheet 90 

23.  Lithotomy  position 91 

24.  Exaggerated  lithotomy  position 92 

25.  Sims'   position 93 

26.  Single  kidney  position 93 

27.  Ventral  position 94 

28.  Knee  chest  position 94 

29.  Dorsal  position,   arms  fastened 95 

30.  Dorsal  position,   ready  for  operation 97 

31.  Dorsal  position,   abdominal  dressing  applied 100 

32.  Dorsal  position,   abdominal  binder  applied 100 

33.  Bed  ready  to  receive  patient 103 


The  Operating  Room 


The  Patient. 


CHAPTER  I. 
THE  OPERATING   ROOM  AND  ITS  PERSONNEL. 

General  considerations.  Arrangement  during  operations.  Prepara- 
tion of  table.  Sinks.  Scrub-up  tray.  Disinfection  of  operating 
room;  table;  nickel;  brass;  glass.  Personnel.  Costumes;  nurses; 
anesthetist;  orderly;  operator  and  assistants;  visitors.  Operating 
room  nurse.  Senior  operating  room  nurse.  Junior  operating  room 
nurse.  Anesthetic  nurse.  Preliminary  training  for  nurses.  Oper- 
ating room  orderly. 

General  Considerations. — The  operating  room  should 
be  on  the  top  floor,  should  have  a  large  floor  space  and 
lofty  ceiling.  The  central  skylight  should  be  double, 
air-tight,  and  made  of  ribbed  glass.  The  east  side  of  the 
room  should  have  large  double  windows.  The  floor, 
walls,  and  ceiling  should  be  tiled.  There  should  be  no 
corners.  The  relation  of  the  operating  room  to  the 
adjoining  rooms  is  shown  in  the  illustration  (frontis- 
piece). 

General  Operating  Room  Rules. — There  should  be  no 
confusion  in  the  operating  room.     Each  person  should  \/ 
be  thoroughly  acquainted  not  only  with  his  or  her  duties, 
but  also  with  the  duties  of  others  employed  in  the  operat-     . 
ing  room.    There  should  be  no  unnecessary  talking.    Each 


12 


OPERATING    ROOM    AND    THE    PATIENT. 


movement  should  be  executed  quickly  and  noiselessly 
and  without  coming  in  contact  with  other  persons. 

The  operating  room  furniture  consist^  of  two  or  more 
operating  tables,  an  instrument  table,  a  sponge  table, 


Crq' 


O 


J 


a  ligature  and  dressing  table,  an  anesthetic  table,  three 
stools,  two  irrigation  stands,  a  stand  for  the  large  bichlo- 
rid  bath,  six  basins  and  stands  for  solutions,  two  screens, 
a  table  for  the  scrubbing  outfit,  four  sinks  with  hot  and 


OPERATING    ROOM    AND     ITS    PERSONNEL.  I3 

cold  water  taps,  a  waste  sink,  pails  and  receptacles  for 
solid  gauze;  gowns,  etc. ;  a  stand  or  inclosure  for  visitors. 

During  an  operation  the  arrangement  is  somewhat  as 
follows :  The  table  is  so  placed  as  to  afford  the  best 
possible  view  of  the  field  of  operation;  the  anesthetist 
seated  at  the  head,  behind  him  and  to  his  right  the  table 
containing  the  anesthetic  outfit  and  the  oxygen  appara- 
tus ;  the  operator  to  one  side  of  the  field  of  operation ; 
his  adjunct  opposite ;  the  house-surgeon  to  the  right  of 
the  operator;  the  senior  assistant  to  the  left  of  the  ad- 
junct; the  instrument  table  behind  the  adjunct-surgeon, 
the  operating  room  nurse  midway  between  the  instru- 
ment table  and  the  adjunct;  the  sponge  table  behind 
the  senior  assistant,  the  senior  operating  room  nurse 
raidway  between  the  sponge  table  and  the  senior  assistant ; 
at  the  operator's  right  stands  a  basin  for  hand  solution; 
also  one  at  the  adjunct's  left;  to  either  side  of  the  table 
is  a  pail  for  soiled  sponges ;  on  one  side  of  the  room  stand 
the  sinks  with  soap,  brushes,  etc.,  in  place  on  the  scrub- 
up  table ;  nearby  in  line  are  the  stands  containing  the 
bichlorid  bath,  alcohol,  permanganate,  oxalic  acid  and 
ammonia  or  aqua  calcis ;  the  visitors'  stand  or  inclosure 
is  so  placed  as  to  be  readily  accessible  from  the  operating 
room  entrance;  the  large  receptacles  for  soiled  dressings, 
gowns,  etc.,  are  at  the  farther  side  of  the  operating  room. 

Preparation  of  Operating  Table. — On  the  table  is 
placed  the  Trendelenburg  crutch,  with  small  rubber  pads 
attached  (to  protect  the  patient's  shoulders),  a  long 
rubber  hot-water  pad  (covered  with  a  sheet),  a  small 
rubber  pillow  (covered  with  a  towel).  The  lithotomy 
posts  and  stirrups  should  be  near  at  hand;  also  the  at- 
tachment for  operations  upon  the  hand  and  forearm. 

Preparation  of  the  Sinks. — Nail  scissors,  nail  files,  wire 
nail  brushes,  a  jar  containing  hand  brushes,  a  jar  of  green 
soap,  a  bottle  of  alcohol,  a  jar  of  chlorid  of  lime,  a  jar  of 
carbonate  of  soda  and  a  bottle  of   hand   lotion  should 


14  OPERATING    ROOM    AND    THE    PATIENT. 

be  on  a  small  table  near  the  sinks.  Bottles  which  are  to 
be  handled  should  have  bichlorid  towels  pinned  around 
them  or  should  be  covered  with  bottle  bags  with  draw- 
strings to  fasten  around  the  neck  of  the  bottle.  This 
prevents  slipping. 

The  scrub-up  tray  is  placed  on  a  small,  movable  table 
in  a  convenient  part  of  the  room.  It  contains  a  large 
flask  of  sterile  water  with  aseptic  cotton  plug,  a  large 
flask  of  acid-bichlorid,  sterile  brushes  in  lo  per  cent, 
bichromate  of  potash  solution,  liquid  green  soap,  tincture 
of  iodin,  Woelfier's  solution,  alcohol,  turpentine,  ether, 
razor,  safety  pins,  bandages,  and  scissors. 

Disinfection  of  the  Operating  Room. — The  walls  of  the 
operating  room  should  be  washed  down  at  least  once  a 
month  with  soap  and  water.  The  furniture  should  be^ 
scrubbed  with  soap  and  water  and  wiped  off  with  bichlo- 
rid (i:iooo)  or  carbolic  (1:20)  after  every  operation, 
when  practicable,  and  certainly  after  every  series  of 
operations.  This  must  also  be  done  after  every  septic 
case.  The  room  should  be  dusted  daily  and  should 
always  be  ready  for  use.  Dusting  or  cleaning  should  not 
be  done  just  before  an  operation.  The  air  of  the  room 
should  be  moist.  All  windows  must  be  kept  closed  and 
draughts  avoided.  In  summer  those  windows  which 
are  to  be  kept  open  in  rooms  adjoining  the  operating 
room  should  be  provided  with  screens.  The  tempera- 
ture of  the  room  should  be  between  75°  and  85°  F.  All 
ventilators  and  heat  registers  are  covered  with  nonab- 
sorbent  cotton  filters.  After  each  series  of  operations 
the  floor  is  flushed  and  scrubbed  with  bichlorid  solution, 
1 :  1000.  Once  each  month  the  operating  room  is  disin- 
fected by  the  formalin  process.  This  method  is  also 
used  after  cases  of  streptococcic  infections.  Steaming 
of  the  operating  room  should  be  done  daily  in  order  to 
keep  the  air  moist  and  prevent  dust.  \ 

Enamelware,  hand  basins,  pitchers,  pus  basins,  dressing 


OPERATING    ROOM    AND    ITS    PERSONNEL.  1 5 

pails  and  other  enamelware  are  scrubbed  with  soap  and 
water  and  rinsed  with  bichlorid,   i:iooo.     After  septic  7 
cases  they  should  be  boiled  for  ten  minutes.     Tables  are  J 

scrubbed  with  soap  and  water,  then  rinsed  with  bichlorid,       X 
i:  looo.     Nickel  work  is  cleansed  daily  with  "  hon  ami''  ^ 
and  polished  with  chamois-skin. 

Brass   work   is    cleansed   daily  with    '' hon  ami''    and  J 
polished  with  a  dry,  soft  cloth. 

Glass  basins  are  cleansed  by  scrubbing  with  soap  and  7  -^ 

water,    rinsed,    wiped   off   with   bichlorid,    and   polished  ] 
with  gauze  wet  with  alcohol. 

Personnel  of  the  Operating  Room. — The  operating 
room  staff  proper  consists  of  an  operating  room  nurse, 
a  senior  operating  room  nurse,  and  two  junior  operating 
room  nurses.  The  position  of  operating  room  nurse  is  a 
permanent  one.  The  senior  and  junior  nurses  serve  in 
each  position  for  at  least  one  month,  during  which  time 
they  are  excused  from  duty  elsewhere  in  the  hospital. 
There  is  an  operating  room  orderly;  also  an  anesthetic 
nurse  who  remains  with  the  patient  until  anesthesia  is 
established  and  later  accompanies  the  patient  to  the  bed, 
remaining  until  the  patient  is  recovered  from  the  anes- 
thetic, ^y" 

The  operating  staff  consists  of  the  operator,  his  ad- 
junct, the  house-surgeon,  the  senior  assistant,  and  the 
anesthetist.  The  resident  bacteriologist  attends  opera- 
tions in  which  cultures  are  desired. 

Operating  Room  Costumes. — Nurses  employed  in  the 
operating  room  shall  wear  over  their  regular  nurse's  cos- 
tume (sleeves  and  cuffs  detached)  a  plain  linen  gown 
with  sleeves  reaching  below  the  elbow.  These  gowns 
fasten  in  the  back,  are  snug  fitting,  and  of  sufficient  -.-^ 
length  to  entirely  cover  the  dress.  A  gauze  mask  is 
worn  which  covers  the  nose  and  mouth.  A  cap,  linen 
or  gauze,  is  so  arranged  as  to  entirely  cover  and  confine 
the  hair.     The  operating  and  sponge  nurses  wear  rubber 


i6 


OPERATING    ROOM    AND    THE    PATIENT. 


gloves   at   the   discretion   of  the   operator.     Gowns   are 
changed  after  each  case  unless  the  operator  otherwise 


Fig.   2. — Nurse's  costume. 


Fig.  3. — Assistant's  costume. 


orders.     Rubbers  or  rubber-soled  shoes  should  be  worn 
to  prevent  slipping. 

The  anesthetist  is  provided  with  a  long-sleeved  gown 


OPERATING    ROOM    AND    ITS    PERSONNEL.  1 7 

having  a  breast  pocket.  He  wears  a  mask  and  cap. 
The  Operating  room,  orderly  wears  a  long-sleeved  gown 
and  cap  and  mask.  Operator's  and  assistant's  gowns 
are  long  sleeved.  Rubber  gloves  are  used  at  the  dis- 
cretion of  the  operator. 

Visitors  are  provided  with  freshly  laundered,  long 
sleeved,  loosely  fitting  linen  gowns.  Each  gown  is 
rolled  up  in  a  compact  package  and  is  not  unrolled  until 
needed.  They  are  put  on  by  the  visitors  before  entering 
the  operating  room.  The  number  of  visitors  is  limited 
to  the  capacity  of  the  visitor's  stand. 

Operating  Room  Nurse. — The  operating  room  nurse  is"^ 
responsible  for  the  care  of  the  operating  room,  the  an- 
esthetic room,  the  instrument  room,  and  all  the  furniture 
and  apparatus  pertaining  thereto.  She  is  responsible  for 
the  preparation  of  all  instruments,  dressings,  ligatures,  sut- 
ures, and  appliances  necessary  for  each  operation ;  also  for 
the  preparation  of  all  dressings  and  bandages  used  in  the 
hospital.  She  should  keep  a  record  of  all  dressings  and 
appliances  issued  to  tl^e  different  wards  of  the  hospital, 
with  the  date  and  amount  of  each  issue,  and  make  a 
monthly  statement  of  the  same.  She  issues  to  each  ward 
the  necessary  dressing  sets,  inspects  these  instruments 
frequently,  and  instructs  the  ward  nurse  in  the  care  of 
such  instruments.  She  stands  at  the  instrument  table 
during  operations  and  passes  such  instruments  to  the  sur- 
geon as  he  may  require.  She  should  endeavor  in  every 
way  to  anticipate  his  wants.  She  watches  closely  the 
nurses  who  assist  her  in  the  operating  room  and  who  are  I 
under  her  direction,  and  sees  that  they  properly  perform 
their  duties.  She  must  not  leave  her  post  at  the  instru- 
ment table  except  at  the  request  of  the  operating  surgeon. 
.  She  personally  prepares  all  ligature  and  suture  material. 
She  allows  no  instrument,  apparatus,  or  dressing  to  leave 
the  operating  room  without  a  written  requisition.     She 


l8  OPERATING    ROOM    AND    THE    PATIENT. 

delivers  such  messages  as  are  reported  to  her  to  the  per- 
son for  whom  such  message  is  intended. 

She  keeps  the  key  to  the  operating  room,  instrument 
room,  and  anesthetic  room.  These  rooms  are  kept  locked 
when  not  in  use.  The  operating  room  nurse  also  sees  that 
all  specimens  are  sent  to  the  pathologic  laboratory,  prop- 
erly labeled  with  the  name  of  the  patient  and  the  hospital 
number.  She  also  sees  that  all  stains  are  removed  from  the 
gowns,  sheets,  etc.,  before  these  are  sent  to  the  laundry. 

Senior  Operating  Room  Nurse. — The  senior  operat- 
ing room  nurse  should  have  four  weeks'  experience  as 
junior  operating  room  nurse  before  becoming  senior. 
Under  the  direction  of  the  operating  room  nurse  she  has 
charge  of  all  the  sterilizing  and  preparation  of  material, 
except  the  ligature  and  suture  material.  Assisted  by 
her  junior,  she  prepares  all  the  supplies  used  in  the 
operating  room  and  also  those  sent  to  the  wards.  On 
operating  days  she  lays  out  the  requisite  number  of 
towels,  protectors,  caps,  masks,  rubber  aprons,  gowns, 
etc.  (everything  except  the  suture  and  ligature  material) , 
necessary  for  the  operations  to  be  performed  that  day. 

During  the  operation,  her  post  is  at  the  sponge  table, 
and  she  shall  not  leave  her  post  except  at  the  request  of 
the  operating  room  nurse.  She  places  bichlorid  towels 
or  protectors  around  the  edges  of  the  hand  basins.  She 
hands  the  operator  and  his  assistants  their  gowns.  She 
passes  all  sponges,  towels,  and  protectors,  anticipating 
the  needs  of  the  operator  as  much  as  possible,  and  is 
responsible  for  the  correct  counting  of  all  sponges. 

After  operations  she  cleans  all  instruments  and  returns 
them  to  their  places.  She  also  washes  out  blood-stained 
gauze,  gowns,  etc.  She  sees  that  the  surgeon's  dressing 
room  is  provided  with  sterilized  gowns  for  visitors  and 
that  the  surgeon's  operating  clothes  are  properly  pre- 
pared. At  operations  in  which  but  one  sterile  nurse  is 
required  the  sponge  table  is  taken  care  of  by  the  operating 


OPERATING    ROOM    AND    ITS    PERSONNEL.  I9 

room  nurse.  The  senior's  term  of  service  should  be  at 
least  one  month. 

Junior  Operating  Room  Nurse. — The  junior  operating 
room  nurse  should  serve  for  at  least  four  weeks  before 
becoming  senior.  She  is  responsible  for  the  dusting  of 
the  instrument  and  supply  room,  the  cases  and  drawers 
of  which  should  be  cleaned  at  least  once  each  week.  The 
room  itself  is  dusted  each  night  before  she  goes  off  duty. 
She  prepares  the  ward  packages  of  towels  for  steriliza- 
tion by  the  senior  nurse.  She  cuts  and  folds  all  the  com- 
presses, and  assists  the  senior  nurse  in  making  bandages, 
sponges,  etc.  She  is  responsible  for  the  cleanliness  of 
all  the  operating  room  and  anesthetic  room  furniture. 
Before  going  off  duty,  she  shall  see  that  the  operating 
room,  instrument  room,  and  anesthetic  room  are  in 
order,  that  the  sinks  and  basins  are  clean,  that  the  soap, 
brushes,  etc.,  are  in  their  respective  places. 

On  operating  days  she  arranges  the  operating  room 
furniture,  prepares  the  basins,  solutions,  anesthetic  room, 
and  the  anesthetic  table.  When  the  patient  is  wheeled 
into  the  operating  room,  the  junior  nurse  assists  in 
placing  the  patient  on  the  table.  She  fastens  the  patient's 
arms  above  the  head  in  operations  upon  the  upper 
abdomen  or  thorax,  across  the  chest,  in  other  abdominal 
and  pelvic  operations.  She  assists  in  placing  the  patient 
in  the  kidney,  lithotomy,  or  Sims'  position  as  required. 
The  blankets  are  smoothly  arranged  so  as  to  completely 
expose  the  parts  to  be  operated  on,  but  no  portion  of 
the  body  is  to  be  left  unnecessarily  uncovered.  She 
removes  the  bandages  and  bichlorid  towels  from  the  site 
of  operation,  taking  care  not  to  bring  her  hand  in  contact 
with  the  patient's  skin.  She  then  assists  the  assistant 
house  surgeon  in  preparing  the  field  of  operation,  pour- 
ing for  him  liquid  green  soap  and  warm  water,  alcohol, 
ether,  alcohol-bichlorid,  acid-bichlorid,  or  iodin-bichlorid 


^ 


20        OPERATING  ROOM  AND  THE  PATIENT. 

as  required.  In  abdominal  cases  she  brings  Woelfler's 
solution  for  the  umbilicus. 

She  then  fastens  the  gowns  of  the  operator  and  his 
assistants ;  places  hand  basins  on  either  side  of  the  table, 
changes  the  hand  solutions  as  they  become  discolored; 
sees  that  the  anesthetist  is  supplied  with  anesthetic; 
picks  up  all  sponges  and  towels  which  drop  to  the  floor 
and  places  them  in  their  proper  receptacles;  picks  up 
fallen  instruments,  cleanses  them,  and,  if  so  ordered, 
sterilizes  them;  collects  the  used  hand  brushes  and 
sterilizes  them;  places  freshly  sterilized  brushes  in  the 
brush  jar  for  each  case;  keeps  the  instrument  sterilizer 
three-quarters  full  of  soda  solution  and  boiling  during 
the  operation;  prepares  and  gives  hypodermatic  in- 
jections as  ordered;  operates  the  thermocautery;  collects, 
counts,  and  places  in  a  pail  near  the  sponge  nurse  all 
soiled  sponges  used  in  a  laparotomy,  and  reports  the 
number  to  the  senior  nurse  and  to  the  operating  room 
nurse.  She  must  be  ready  at  all  times  to  give  the  sponge 
count ;  sees  that  the  saline  solution  is  kept  at  the  proper 
temperature ;  takes  all  messages  coming  to  the  operating 
room  and  reports  them  to  the  operating  room  nurse. 

Between  operations  she  washes  the  frame  of  the 
chloroform  mask  or  ether  cone,  changes  the  covers,  and 
replaces  the  soiled  hair  bag  of  the  latter  with  a  fresh  one. 
She  brings  a  dry,  warm  blanket  for  the  patient  and 
assists  the  ward  nurse  to  prepare  the  patient  to  leave 
the  operating  room  (dry  shirt,  stockings,  etc.) ;  flushes 
the  operating  room  floor  with  bichlorid  solution  after 
each  case;  removes  the  protectors  from  the  hand  basins, 
flushes  the  basins  with  sterile  water  and  refills  them  with 
bichlorid;  cleans  and  prepares  the  operating  table  for 
the  next  case;  collects  soiled  gowns,  towels,  sponges, 
etc.,  and  places  them  in  their  respective  receptacles. 

On  the  completion  of  an  operation  or  series  of  operations 
she  rinses  out  the  stains  in  the  operating  room  clothing 


OPERATING    ROOM    AND    ITS    PERSONNEL.  21 

and  towels,  and  prepares  them  for  the  laundry.  She 
cleanses  the  rubber  aprons  with  soap  and  water  and 
wipes  them  off  with  carbolic  solution;  cleans  all  the 
operating  room  furniture,  anesthetic  table,  etc. ;  sees 
that  the  solutions  are  all  in  order,  reporting  any  defi- 
ciency to  the  operating  room  nurse;  refills  all  solutions; 
and  cleanses  all  glassware,  basins,  blood-stained  gauze, 
etc. 

She  must  watch  the  operating  room  nurse,  the  senior 
nurse,  and  the  anesthetist  and  anticipate  their  needs  as 
much  as  possible.  She  must  not  leave  the  room  unless 
ordered  to  do  so  by  the  operating  room  nurse.  She  sees 
that  each  visitor  is  provided  with  a  gown. 

The  second  junior  nurse  should  be  familiar  with  the 
duties  of  the  first,  so  that  when  two  operations  are  pro- 
ceeding simultaneously  she  may  help.  At  other  times 
she  is  employed  in  preparing  dressings  and  material. 

The  Anesthetic  Nurse  accompanies  the  patient  from 
the  ward  to  the  anesthetic  room  and  remains  there  until 
the  patient  is  taken  to  the  operating  room.  She  marks 
on  the  anesthetic  slip  her  name,  the  name  of  the  patient, 
the  variety  of  anesthetic,  the  time  begun,  and  the  time 
established;  also  the  patient's  pulse  when  the  anesthetic 
is  established.  She  pins  this  slip  on  the  anesthetist's 
gown.  She  watches  the  pulse  carefully,  noting  its 
quality  and  counting  it  frequently,  and  reporting  its 
rate  to  the  anesthetist.  She  assists  in  controlling  any 
struggling  of  the  patient.  She  gives  hypodermatic  in- 
jections when  ordered  to  do  so  by  the  anesthetist.  She 
must  be  familiar  with  the  use  of  the  oxygen  tank.  She 
sees,  just  previous  to  the  patient's  being  taken  to  the 
operating  room,  that  the  patient's  cap  is  on  properly 
and  that  the  blankets  are  smoothly  arranged. 

Course  Preliminary  to  Entering  Operating  Room  Train- 
ing.— The  supervisor  of  nurses  should,  so  far  as  is  practi- 
cable, arrange  a  list  of  nurses  for  operating  room  training. 


22  OPERATING    ROOM    AND    THE    PATIENT. 

These  nurses  shall,  so  far  as  possible,  attend  operations 
and  by  observation  and  study  acquaint  themselves  with 
their  future  duties. 

Operating  Room  Orderly. — The  operating  room  orderly 
remains  with  the  patient  while  in  the  anesthetic  room, 
controls  any  struggle  on  the  part  of  the  patient,  wheels 
the  patient  into  the  operating  room,  assists  the  anesthet- 
ist in  placing  the  patient  on  the  table,  and  sees  that  the 
pad  of  the  anesthetic  cart  and  the  pillow  remain  on  the 
cart.  He  removes  the  "lifter"  (small  stretcher)  from 
under  the  patient  and  then  removes  the  cart  to  the 
anesthetic  room.  Should  the  cover  of  the  pad  or  pillow 
be  soiled,  he  removes  the  cover,  places  it  in  the  soiled 
clothes  receptacle,  wipes  off  the  soiled  rubber  coverings 
with  bichlorid,  i  :  looo,  and  puts  on  fresh  linen  covers. 
He  brings  the  tray  containing  the  anesthetic  outfit  from 
the  anesthetic  room  and  places  it  upon  a  table  placed 
at  the  right  and  behind  the  anesthetist.  Should  the 
operation  be  one  involving  the  male  genitalia,  the  orderly 
should  remain.  He  places  screens  around  the  operating 
table,  brings  to  the  assistant  house  surgeon,  the  soap  and 
water,  alcohol,  ether,  and  bichlorid  or  acid-bichlorid  solu- 
tion as  required,  and  performs  such  duties  ordinarily 
performed  by  the  junior  operating  room  nurse  as  shall  be 
assigned  to  him.  In  cases  in  which  he  is  not  needed  in 
the  operating  room  he  remains  in  the  anesthetic  room 
and  holds  himself  in  readiness  to  receive  orders  from  the 
operating  room  nurse.  Such  messages  are  delivered  to 
him  through  the  medium  of  the  junior  nurse. 


1 


y 


CHAPTER  II. 
THE  INSTRUMENT  AND  SUPPLY  ROOM. 

General  Considerations. — The  instrument  and  supply 
room  should  communicate  directly  with  the  operating 
room.  It  should  be  a  large  room  fitted  with  numerous 
drawers  and  shelves  capable  of  containing  all  the  supplies 
needed  for  use  in  the  operating  room.  The  furniture 
consists  of  three  enamel  chairs;  one,  long,  narrow  enamel 
table  for  preparing  supplies ;  bandage  roller ;  an  apparatus 
for  preparing  plaster-of- Paris  bandages;  and  a  dust- 
proof  instrument  case.  Glass  bowls,  mortar  and  pestle, 
glass  graduates,  and  mixing  rods  should  be  kept  on  a 
shelf  above  the  supply  table.  A  shelf  should  be  reserved 
for  books  relating  to  aseptic  technic,  surgical  bacteriology, 
operative  surgery,  and  instruments. 

Instruments  should  be  kept  in  their  proper  places  in 
the  instrument  case  when  not  in  use.  Knives  should 
be  kept  in  racks  to  prevent  dulling.  Needles  should  be 
kept  in  needle  trays.  So  far  as  practicable,  instruments 
should  be  kept  in  sets  representing  the  operations  for 
which  they  are  commonly  used.  Instruments  in  part 
made  of  soft  rubber  should  be  kept  in  a  separate  drawer. 
No  rubber  goods  should  be  kept  in  the  instrument  cabi- 
net. Sets  of  instruments  the  property  of  individual 
operators  should  be  kept  separate  from  the  hospital 
instruments.  Duplicate  sets  of  instruments  may  be  con- 
veniently kept  in  linen  holders. 

Metal  instruments  (except  edged  instruments)  are 
sterilized  by  boiling  from  ten  to  thirty  minutes  in  a  i 
per  cent  solution  of  carbonate  of  soda.     This  should  be 

23 


24 


OPERATING    ROOM    AND    THE    PATIENT, 


done  just  before  the  instruments  are  to  be  used.  They 
are  taken  frora  the  steriHzer,  drained,  placed  on  a  sterile 
sheet,  arranged,  and  covered  with  sterile  towels.     Edged 


in 


^ 


instruments  with  locks,  such  as  scissors  and  bone-cutting 
forceps,  are  boiled  for  five  minutes.  They  are  boiled 
separately  from   the  other  instruments   and  on  a  rack 


INSTRUMENT    AND    SUPPLY    ROOM.  2$ 

which  keeps  them,  from  contact  with  the  bottom  of  the 
steriHzer  and  so  in  part  prevents  vibration.  Knives  are 
boiled  for  two  minutes  in  special  racks  so  constructed 
as  to  keep  their  edges  uppermost.  Needles  are  boiled  V 
for  three  minutes  in  an  open  metal  box.  During  sterili- 
zation the  sterilizer  should  be  covered.  There  should 
always  be  sufficient  soda  solution  in  the  sterilizer  to 
cover  the  instruments. 

Directly  after  use,  instruments  should  be  washed, 
piece  by  piece,  in  running  cold  water  until  all  blood- 
stains are  removed.  This  cleansing  is  facilitated  by  the 
use  of  a  piece  of  gauze.  Particular  attention  is  paid  to 
locks  and  crevices.  Instruments  are  then  boiled  from 
ten  to  thirty  minutes  in  soda  solution.  Following  this, 
they  are  scrubbed  with  warm  water  and  ''hon  ami"  until 
bright;  rinsed  in  warm  water,  thoroughly  dried  with 
gauze,  polished  with  a  soft  chamois,  and  put  in  their 
places  in  dust-proof  cabinets.  Each  week  the  cutting 
edge  instruments  that  have  been  used  during  the  week 
are  sent  to  be  set  and  sharpened.  There  should  be  a 
sufficient  number  of  knives  to  allow  one  fresh  knife  to 
each  operation  during  the  week.  The  instrument  nurse 
should  be  able  to  sharpen  the  knives.  Instruments  out 
of  repair  should  be  sent  at  once  to  the  maker. 

Brushes. — Brushes  are  sterilized  by  boiling  for  one- 
half  hour  in  a  lo  per  cent,  solution  of  bichromate  of 
potash.  They  are  transferred  and  kept  in  covered  glass 
jars  containing  the  same  strength  solution  of  bichromate 
of  potash  in  i  :  looo  bichlorid.  After  using  they  are 
boiled  for  ten  minutes  and  replaced  in  the  glass  jars. 
The  bichromate  of  potash-bichlorid  solution  is  renewed 
at  the  end  of  each  operating  day.  The  use  of  this  solu- 
tion keeps  the  brushes  in  good  condition  and  makes 
them  last  longer.  Brushes  should  be  of  the  common 
hand  brush  variety,  of  good  quality,  and  not  so  stiff  as  to 
abrade  the  skin. 


26 


OPERATING    ROOM    AND    THE    PATIENT. 


Soap. — Several  varieties  of  soap  should  be  kept  in 
stock.  The  soap  commonly  used  is  the  sapo  viridis  of 
the  German  pharmacopoeia.  Tincture  of  green  soap  is 
a  convenient  form.  A  good  antiseptic  soap  may  be  made 
as  follows: 


Or; 


R. 


M. 


R. 


M. 


Ether, 

Alcohol, 

Turpentine, 

Glycerini, aa  Biss. 

Sapo  viridis, § vj. 

Hydrarg.  bichlorid., q.  s.  ad  i  :  looo. 

Sapo  viridis, Bx. 

Alcohol, Bxx. 

Glycerini, Bvij. 

01.  bergamot., 3ij. 


Fig.   5. — Nail  cleaner. 


Nail  cleaners,  nail  files,  and  nail  scissors  should  be 
kept  in  a  special  tray  near  the  sinks.  In  addition  to  the 
nail  cleaners  usually  employed,  much  satisfaction  will 
be  experienced  in  using  the  one  devised  by  Dr.  George  R. 
Fowler.  By  its  use  injury  to  the  matrix  of  the  nail  is 
avoided  and  thorough  cleanliness  is  assured. 


INSTRUMENT    AND    SUPPLY    ROOM.  27 

Chlorinated  lime  and  sodium  carbonate  should  be  kept 
in  separate  stone  jars.  That  containing  the  lime  should 
be  air-tight.  A  ready  means  of  disinfecting  the  hands 
after  septic  operations  consists  in  making  a  paste  with 
a  small  quantity  of  each  of  these  ingredients  and  water. 
This  is  rubbed  well  into  the  skin  for  a  few  minutes  and 
then  rinsed  off  with  warm  water.  The  combination 
gives  off  chlorin  gas.  It  is  quite  irritating  if  left  on  the 
skin  for  any  length  of  time  or  if  used  as  a  routine  proce- 
dure. 

Hand  lotions  are  at  times  useful  in  allaying  irritation 
of  the  skin  from  too  vigorous  scrubbing  or  from  the 
chemical  solutions.  A  simple  lotion  may  be  made  as 
follows : 

R.     Acid,  acetic,  dilut., 

Alcohol., 

Glycerini, 

Acid,   boric,  (sat.  sol.), aa  oj- 

Aquas  rosse, Siv. 

M. 

No  hand  lotion  will  make  up  for  lack  of  care  in  the 
cleansing  of  the  hands  following  operations. 

Caps  are  made  of  bleached  muslin  in  three  styles: 
surgeons'  caps,  nurses'  caps,  and  patients'  caps.  They 
should  be  made  in  several  sizes  and  be  large  enough  to 
come  well  over  the  occipital  protuberance,  covering  all 
the  hair.  Patients'  caps  may  be  made  of  unbleached 
muslin.  In  form  they  resemble  the  ordinary  bath  cap, 
except  that  in  place  of  an  elastic  they  have  a  drawstring 
which  fastens  at  the  back  of  the  neck. 

Masks  are  made  of  oblongs  of  muslin  ten  inches  by 
six  inches.  Each  long  side  is  turned  in  and  a  drawstring 
run  through. 

Rubber  aprons  are  preferably  made  of  double-faced, 
red  rubber  sheeting.  Such  sheeting  is  more  durable 
than  the  single  faced.     A  sheet  one  yard  long  and  twenty 


28  OPERATING    ROOM    AND    THE    PATIENT. 

inches  wide  makes  the  average  apron.  Elastic  rubber 
tubing  is  preferable  to  tape  for  holding  the  aprons  in 
place.  The  aprons  are  cleaned  after  each  use  by  scrub- 
bing with  soap  and  water,  then  wiping  off  with  carbolic 
acid  1 :  40,  and  hung  up  to  dry. 

Gowns  are  of  two  varieties:  operators'  and  nurses'. 
Gowns  having  closely  fitting  long  sleeves  are  preferable 
to  short-sleeved  gowns,  as  the  gowns  are  easily  sterilized, 
while  the  skin  is  not.  Gowns  are  washed  and  laundered 
in  the  usual  manner,  then  each  gown  is  rolled  into  a 
compact  package  inclosed  in  heavy  sheeting  material. 
They  are  sterilized  by  steam  for  one-half  hour  on  the 
day  of  the  operation. 

Rubber  gloves  are  sterilized  by  boiling  for  five  minutes 
in  saline  solution.  They  are  then  immersed  and  filled 
with  bichlorid,  i :  3000,  and  put  on.  The  gloves  should 
have  gauntlets  which  come  well  up  on  the  forearm. 
They  should  be  tested  before  each  time  of  using  by 
filling  them  with  bichlorid  solution  to  detect  any  needle 
holes  or  tears.  They  are  worn  during  all  operations  by 
the  nurses  and  assistants,  but  they  should  not  be  put 
on  until  after  thorough  mechanic  disinfection  of  the 
hands.  The  objection  to  their  use  is  that  they  macerate 
the  skin  and  so  bring  hordes  of  bacteria  to  the  surface. 
Should  a  needle  hole  or  tear  exist  or  be  made  during  the 
course  of  the  operation,  these  bacteria  are  likely  to  escape. 
If  injury  to  the  gloves  occurs,  the  nurse  should  immedi- 
ately retire  from  the  operation,  redisinfect  her  hands, 
and  don  fresh  gloves.  The  use  of  a  drying  powder, — 
i.  e.,  alum, — as  advocated  by  Dawbarn,  prevents  sweating 
to  a  certain  extent.  After  using,  gloves  should  be 
washed  in  soap  and  water,  then  boiled  in  saline  solution 
for  two  minutes,  rinsed  in  water,  the  outside  dried, 
turned  inside  out,  and  hung  up  to  dry.  The  surfaces 
may  be  kept  from  coming  in  contact  and  adhering  by 
blowing  into  the  glove  occasionally  or  by  packing  the 
fingers  with  strips  of  gauze. 


INSTRUMENT  AND  SUPPLY  ROOM.  29 

Gloves  are  also  useful  in  vaginal  and  rectal  examina- 
tions, in  the  examination  of  infected  wounds,  and  as  a 
safeguard  to  surgeons  in  septic  cases. 

Finger  cots  of  thin  rubber  are  useful  in  examinations  and 
to  protect  small  abrasions  on  the  surgeon's  fingers  against 
infection.  They  may  be  put  on  the  first  and  little  finger 
of  each  hand  in  cases  in  which  many  ligatures  are  to  be 
tied  and  will  aid  in  preventing  the  cut  which  the  tying 
of  many  ligatures  frequently  makes  in  the  creases  of 
these  fingers. 

They  are  prepared  and  cared  for  in  the  same  manner 
as  rubber  gloves,  except  they  stand  but  one  minute's 
boiling.  They  are  so  cheap,  however,  that  they  may  be 
thrown  away  after  each  use. 

Protectors  are  made  of  heavy  linen  or  of  unbleached 
muslin  in  two  sizes,  one  and  one -half  yards  by  one  and 
three-fourths  yards,  and  one  and  one-half  yards  by  three- 
fourth  yard.  They  serve  to  cover  the  patient  except 
the  part  to  be  operated  upon.  They  are  sterilized  by 
fractional  steam  sterilization  in  sets  of  two,  one  large  and 
one  small,  rolled  into  a  compact  package  done  up  in 
heavy  sheeting  material. 

•  Laparotomy  sheets  are  made  of  heavy  linen  or  un- 
bleached muslin.  They  should  be  long  enough  to  cover 
the  entire  body  and  drape  over  the  sides  and  foot  of  the 
table.  Through  the  center  of  that  part  of  the  sheet  which 
covers  the  abdomen  a  twelve-inch  slit  is  made  and  the 
edges  hemmed.  Each  sheet  is  sterilized  in  an  individual 
package. 

Perineal  sheets  are  used  to  cover  in  the  feet,  legs, 
thighs,  buttocks,  and  lower  abdomen  of  patients  in  the 
lithotomy  position.  They  are  two  yards  in  length  by 
one  in  breadth.  Each  short  side  has  a  pocket  arrange- 
ment which  covers  the  patient's  foot.  Through  the 
center  of  that  portion  which  covers  the  perineum  and 
vagina  is  a  twelve-inch  slit.  Each  sheet  is  sterilized  in 
an  individual  package. 


30  OPERATING    ROOM    AND    THE    PATIENT. 

Anus  protectors  for  use  in  vaginal  operations  are  made 
in  two  patterns.  One,  a  two-tailed  bandage  of  several 
thicknesses  of  gauze,  the  tails  lying  upon  the  abdomen, 
the  body  of  the  protector  over  the  anus.  The  tails 
should  be  long  enough  to  lie  well  up  on  the  abdominal 
surface  to  preclude  slipping.  The  body  of  the  protector 
is  held  in  place  by  the  speculum.  The  other  pattern  is 
a  piece  of  toweling  to  the  two  upper  corners  of  which  are 
sewn  double  pieces  of  tape.  These  pieces  of  tape  tied 
around  the  lithotomy  posts  serve  to  draw  the  towel 
tightly  over  the  anus.  An  anus  protector  should  be 
sterilized  in  the  package  with  the  perineal  sheet.  A 
third  and  convenient  variety  of  anus  protector  consists 
of  a  towel  held  in  place  over  the  anus  and  buttocks  by 
a  broad  strip  of  adhesive  plaster,  one-half  of  the  towel 
being  folded  back  over  the  adhesive  plaster. 

Towels  should  be  made  of  dish  toweling  of  good  quality. 
They  should  be  thirty  inches  in  length  by  twenty  inches 
in  width,  and  hemmed.  They  are  folded  separately  and 
sterilized  by  steam  in  packages  of  six. 

Blankets  for  use  in  the  operating  room  should  be  the 
ordinary  single  blanket  cut  in  half.  This  size  is  most 
convenient  for  wrapping  around  the  legs  of  patients  or 
placing  over  the  chest.  They  are  laundered  and  sterilized 
after  each  use. 

Screen  Covers  should  be  changed  weekly  or  as  often 
as  soiled.  The  light-weight  canvas  kind  which  are 
provided  with  eyelets  and  lace  to  the  frame  are  best. 

Rubber  sheeting  should  be  kept  in  stock  for  making 
pads  for  the  operating  table  and  for  rubber  aprons. 
Several  sheets  one  yard  by  thirty  inches  should  be  kept  on 
hand  to  place  under  the  patient  to  act  as  drainage  pads 
during  dressings. 

Kelly  pads,  two  in  number,  should  be  scrubbed  with 
soap  and  water  and  wiped  off  with  i :  40  carbolic  solution 
after  each  use. 


INSTRUMENT    AND    SUPPLY    ROOM.  3 1 

Covers  for  the  rubber  pads  used  on  the  operating  table 
and  anesthetic  cart  should  be  of  stout  muslin.  These 
are  fresh  for  each  case.  Muslin  bottle  bags  should  be 
kept  in  stock  in  various  sizes  and  fresh  ones  used  for 
each  series  of  operations.  Muslin  hand,  foot,  arm,  and 
leg  bags,  with  drawstrings,  are  useful  in  operations  in 
the  neighborhood  of  these  parts. 

Sheets,  gowns,  towels,  blankets,  etc.,  are  secured  in 
convenient  packages  and  sterilized  at  least  one  hour 
before  operations.  If  these  sterilized  bundles  have  not 
been  opened  for  forty-eight  hours  they  are  resterilized 
before  using. 

Powders  for  use  in  making  up  dressings  and  solution 
should  be  kept  dry  in  wide-mouthed,  screw-cap  jars. 
'     Iodoform. — This   should   be    finely   powdered   by   the 
mortar  and  pestle  before  using. 

Zinc  oxid  for  making  zinc  oxid  gauze  and  for  use  as  a 
dusting  powder. 

Saline  powders  for  making  up  solution  for  intravenous 
infusion,  made  as  follows : 

R.      Sodii  chlorid., 5iv  gr.  vj. 

Sodii  sulphat., gr.  xj. 

Sodii  phosphat., gr.  iiif . 

Sodii  carbonat., gr.  vss. 

Calcii  phosphat., gr.  ix^. 

Magnes.  phosphat gr.  iv^. 

M.  Sig. — One  powder  to  six  quarts  and  nine  ounces  of  sterile 
water, 

Potassium  permanganate  crystals  should  be  made  up 
in  one  ounce  packages. 

Oxalic  acid  crystals  should  be  made  up  in  one  and 
one-half  ounce  packages. 

Thiersch  powders  contain    15    grains   of  salicylic   acid 
and  90  grains  of  boric  acid. 
^      Boric    acid   for  making  Thiersch  powder,  gauze,  and 
solutions  and  for  use  as  a  dusting  powder. 


32  OPERATING    ROOM    AND    THE    PATIENT. 

Salicylic  acid  for  making  Thiersch  powder. 

Bichlorid  of  mercury  made  up  in  tablets  of  7-|  grains 
(one  to  one  pint  of  fluid  makes  a  1:1000  solution)  and 
for  making  stock  solutions.  Sufficient  acid  should  be 
added  to  make  the  solution  acid  in  reaction. 

Carbonate  of  soda  (oiiss  to  the  quart  makes  a  i  per 
cent,  solution)  to  make  up  solution  for  sterilizing  in- 
struments. 

Bicarbonate  of  soda,  to  make  up  a  saturated  solution 
(Siioiiss  to  the  quart)  for  mixing  with  equal  parts  of  per- 
oxid  of  hydrogen  for  use  as  an  irrigation. 
r  Sodium  Chlorid  made  up  in  one  drachm  packages  and 

sterilized  by  dry  heat. 
y"       Magnesia  sulphate  made  up  in  one  ounce  packages  for 
use  in  intestinal  obstruction  cases. 

Bichromate  of  potash  in  packages   G^iss  gr.  xlviii)  for 
making  the  solution  for  the  hand  brushes  (one  package 
to  the  pint  makes  10  per  cent,  solution). 
^  Cocain  hydrochlorate  in  one-half  grain  tablets  for  mak- 

ing up  spray  and  hypodermatic  solutions. 

Solutions. — All  water  used  in  making  solutions  should 
be  sterilized  and  all  solutions  should  be  carefully  labeled. 
,„^  Bichlorid    of   mercury. — The    stock    solution    may   be 

either  5  per  cent,  or  12^  per  cent,  bichlorid  in  alcohol. 
It  should  be  kept  in  a  blue  bottle.  Of  the  first,  Sj  to 
the  gallon  makes  a  i :  3000 ;  of  the  second,  5iv  to  the 
gallon  makes  a  1:2000  solution;  other  strengths  in  pro- 
portion. A  small  quantity  of  anilin  blue  added  to  the 
stock  solution  is  sufficient  to  color  all  the  solutions  and 
distinguishes  them  from  other  solutions.  Sufficient  hy- 
drochloric acid  should  be  added  to  cause  an  acid  reac- 
tion in  all  bichlorid  solutions. 

Acid  bichlorid  is  made  in  the  proportion  of  water, 
30  parts;  alcohol  (94  per  cent.),  60  parts;  hydrochloric 
acid,  6  parts;  bichlorid,  to  make  a  strength  of  1:1250 
(Harrington's  formula). 


INSTRUMENT  AND  SUPPLY  ROOM.  33 

^y-  Carbolic  acid  solution  should  be  made  hot.  Stock 
solution,  95  per  cent.;  Svj  to  i  gallon  makes  a  1:20 
solution;  other  strengths  in  proportion.  Also  used  pure 
in  the  disinfection  of  suppurating  cavities.  When  used 
in  this  manner  a  quantity  of  absolute  alcohol  should  be 
at  hand. 

Boric  acid,  ovj  to  the  gallon,  makes  a  saturated  so- 
lution.  Add  the  crystals  while  the  water  is  hot;  then 
filter. 

Thiersch    solutwn    (boro-salicylic    solution) :    salicylic 
v/    acid,  15  grains;  boric  acid,  90  grains  to  the  pint.     Add 

the  powder  after  the  water  has  cooled ;  then  filter. 
r  Normal  sahne  solution. — Sterile  sifted  salt,  5j  to  the 
■^  pint.  Dissolve  in  sterile  water.  Filter  into  flasks 
(sterilized  by  washing  with  bichlorid  solution,  then 
rinsing  with  sterile  water),  stopper  with  nonabsorbent 
cotton,  sterilize  for  one  hour  for  three  succesive  days  at 
a  temperature  of  220°  F.,  and  cover  the  cotton  stopper 
with  a  small  square  of  rubber  tissue  held  in  place  by  a 
rubber  band.  When  needed,  place  the  flask  in  a  deep 
basin  filled  with  hot  water  until  raised  to  the  required 
temperature.  A  special  saline  powder  may  be  used,  but 
this  is  not  essential.  Stock  salt  solution  may  be  kept 
in  order  to  make  normal  salt  solution  quickly.  The 
sodium  chlorid  used  should  be  dried  sufficiently  to 
granulate.  Add  giss  (47  gm.)  of  the  salt  to  Sviii  (237 
cubic  centimeters)  of  water.  Boil  in  a  closed  vessel  for 
fifteen  minutes ;  oj  of  the  solution  to  .^viii  of  sterile  water 
makes  normal  saline  solution. 

Bichlorid-pernianganate  Solution. — Potassium  perman- 
ganate crystals,  oj ;  bichlorid  of  mercury,  gr.  viiss ;  to 
I  quart  of  hot,  sterile  water.  The  solution  should  be 
made  shortly  before  using. 

Permanganate  of  Potassium  Solution. — Crystals,  .5j ;  hot, 
sterile  water,   i  quart.     Should  be  made  shortly  before 
using. 
3 


w/ 


J 


34  OPERATING    ROOM    AND    THE    PATIENT. 

Oxalic  Acid  Solution.— Cry stsls,  Siss ;  hot  water,  i  quart. 
Should  be  made  shortly  before  using. 

Ammonia  Solution. — Stronger  ammonia,  Sj ;  cold  water, 
I  quart.  Should  be  made  shortly  before  using.  For  neu- 
tralizing the  effects  of  the  oxalic  acid. 

Lime-water,  for  neutralizing  oxalic  acid. 

Iodoform  emulsion,  lo  per  cent. 

R.     Iodoform  (finely  powdered), 5 j. 

Glycerini, 5  ix. 

Put  glycerin  in  wide-mouthed  bottle,  cork,  and  sterilize  by  steam 
for  fifteen  minutes;  add  iodoform  gradually,  shaking  the  mixture 
every  few  minutes. 

Chlorid  of  zinc  solution,  lo  per  cent.,  for  use  as  an 
escharotic  in  cancer  of  the  cervix  and  in  sloughing  pro- 
cesses. 

R.     Chlorid  of  zinc gr.  384. 

Distilled  water, 5  viij. 

Bichromate  of  potash  solution,  10  per  cent. 

R.     Bichromate  of  potash, §iss  gr.  xxx. 

Water,  sterilized i  pint. 

This  solution  is  used  for  sterilizing  and  preserving 
hand  brushes. 

Woelfler's  solution  is  compound  tincture  of  benzoin  to 
which  10  per  cent,  iodoform  powder  has  been  added.  It 
should  be  shaken  before  using.  Sufficient  bichlorid  of 
mercury  to  make  a  strength  of  i :  1000  may  be  advan- 
tageously added.  For  use  as  a  peritoneal  varnish ;  to  fill 
the  umbilicus  after  cleansing ;  to  coat  the  nipple  in  breast 
operations. 

Tincture  of  iodin,  for  painting  on  the  proposed  line  of 
incision  to  disinfect  the  skin.  Bichlorid  to  make  a 
i:  1000  solution  may  be  added. 

Benzin,  for  use  in  the  thermocautery  and  for  cleansing 


INSTRUMENT  AND  SUPPLY  ROOM.  35 

eczematous  condition  of  the  skin,  such  as  are  found  in  the 
neighborhood  of  fecal  fistulas.  Great  care  must  be  ex- 
ercised in  handling  benzin,  as  it  is  very  infiammable. 
It  is  very  useful  in  removing  adhesive  plaster  straps. 

Alcohol,  50  per  cent,  for  general  use  in  cleansing  and     ' 
adding  to  hand  solutions ;    80  per  cent,  for  the  hands ; 
absolute  for  sterilization  of  catgut. 

Sterile  water  should  be  kept  in  well-stoppered  flasks. 
The  hot  and  cold  sterile  water  apparatus  should  give  a 
generous  supply. 

Hydrogen  peroxid  kept  in  brown  or  blue  glass  bottles,     y' 
The  bottles  should  not  be  filled  entirely,  but  an  air  space 
should  be  left  above  the  solution. 

Sodium  bicarbonate  (saturated  solution),  for  neutraliz-    ^■^ 
ing  the  hydrogen  peroxid  just  previous  to  use. 

Commercial  ether,  for  cleansing  purposes.  y^ 

Glycerin,   for  use  as  a   lubricant;    for  tampons;    for      ..y 
preparing  catgut. 

Balsam  of  Peru,  for  gauze  dressings.  -y''' 

Ichthyol,  for  adding  to  glycerin  to  make  10  per  cent.      /v'^ 
tampons. 

Vaseline  in  small,  glass  jars  for  use  as  a  lubricant.      -v^ 
Should  be  sterilized  after  each  one. 

Olive  oil,  for  use  as  a  lubricant. 

Whale  oil  and  iodoform  mixture,  for  filling  bone  cavities. 

Paraffin,  of  a  melting  point  of  120°  F.,  for  preparing    -7/ 
silk  sutures ;  for  preparing  paper  coverings  for  dressings ; 
for  injection  purposes. 

Cocain  Solutions. — Solutions  of  cocain  should  be 
freshly  prepared.  A  ^  per  cent,  solution  is  2^  grains  to 
the  ounce ;  i  per  cent,  solution,  4^^  grains  to  the  ounce ; 
2  per  cent,  solution,  9  grains  to  the  ounce ;  other  strengths 
in  proportion. 


y 


-^ 


/ 


CHAPTER  III. 
THE  INSTRUMENT  AND  SUPPLY  ROOM.  (Continued.) 

GAUZES. 

All  gauze  previous  to  use  or  to  impregnation  with 
antiseptics  is  sterilized  by  steam  for  a  half -hour  each  day, 
at  a  temperature  of  212°  F.,  for  three  successive  days. 
In  the  preparation  of  all  gauzes,  strict  asepsis  of  the  hands 
and  all  utensils  is  to  be  observed. 

Iodoform  Gauze    No.  i. — ^Formula: 

Iodoform  powder gr.  1 16. 

Glycerin, 5 j- 

Alcohol, oij- 

Mix  thoroughly.  This  quantity  of  iodoform  makes  a 
lo  per  cent,  gauze.  For  more  strongly  impregnated 
gauze  use  iodoform  in  proportion.  This  quantity  is 
sufficient  to  impregnate  one  yard  of  gauze.  The  gauze 
should  first  be  sterilized  by  fractional  steam  sterilization 
for  three  successive  days.  The  iodoform  emulsion  is 
evenly  distributed  through  the  gauze  by  repeatedly 
pressing  the  gauze  into  the  liquid  and  wringing  it  out. 
The  gauze  is  then  folded  or  rolled  in  convenient  shape 
and  placed  in  sterile,  glass,  air-tight,  light-proof  recepta- 
cles. Finally,  the  gauze  is  sterilized  by  steam  heat  for 
one  hour  at  a  temperature  not  exceeding  212°  F. 
Iodoform  Gauze  No.  2. — Formula: 

Iodoform  powder, 5ss. 

^  Glycerin 5  j. 

Hydrarg.  bichlorid,  (i  :  2000) Oj. 

36 


INSTRUMENT  AND  SUPPLY  ROOM. 


37 


Mix  thoroughly.     The  bichlorid  solution  is  made  with 
sterile  water.     Cut  the  gauze  into  strips  five  yards  long 


a, 

a, 

w 

PI 


bo 


and  four  inches  wide  and  fold  or  roll.  Sterilize.  Im- 
raerse  in  the  above  mixture,  then  sterilize  by  steam 
heat,  212°  F. 


38  OPERATING    ROOM    AND    THE    PATIENT. 

Iodoform  Gauze  No.  3. — Formula: 

'   /  /  Iodoform  powder, 5  j. 

Glycerin, 5  viij. 

Alcohol, Oj. 

Sterile  water, B viij. 

Mix  the  iodoform  and  glycerin,  then  add  the  alcohol  and 
sterile  water.     Proceed  as  above. 
Iodoform  Gauze  No.  4. — Formula : 

Iodoform  powder, §iv. 

Glycerin, Bx. 

Alcohol, oxxxv. 

Ether, Oj. 

Mix  the  iodoform  powder  and  glycerin.  Let  stand  for 
twenty -four  hours,  then  mix  again  and  add  alcohol  and 
ether.  Proceed  as  above.  This  formula  is  the  best  for 
impregnating  gauze. 

Zinc  Oxid  Gauze. — Formula: 

Zinc  oxid  powder, 5ss. 

Glycerin, B  j. 

Sterilized  water  (warm), Oj. 

Mix  thoroughly.  Cut  the  gauze  in  strips  five  yards  long 
and  three  and  one-half  inches  wide;  immerse  in  the 
solution,  squeeze  out,  roll  or  fold,  place  in  sterile  glass 
jars, — sterilize  for  one -half  hour  by  steam  heat  on  three 
successive  days,  and  seal. 

Boric  Acid  Gauze. — Cut  gauze  in  strips  as  above,  boil 
for  one-half  hour  in  saturated  solution  of  boric  acid, 
then  sterilize  as  for  zinc  oxid  gauze. 

Bichlorid  of  Mercury  Gauze.— Formula : 

Strength, i  :  looo       i  :  500         i  :  400. 

Absorbent  gauze  (dry) 13  av.  oz.  13  av.  oz.  13  av.  oz. 

Sol.  bichlorid,  (i  :  1000),    ....  12^  oz.       25  oz.         31  oz. 
Sterilized  water, q.  s.  ad  32  oz.  32  oz.  32  oz. 


INSTRUMENT    AND    SUPPLY    ROOM.  39 

After  the  gauze  has  been  thoroughly  saturated,  dry 
in  a  dust-proof  place  and  preserve  in  light-proof  jars. 

Thiersch  Gauze. — Prepare  Thiersch  solution,  1:50  (pro- 
portion: boric  acid,  gr.  viij ;  salicylic  acid,  gr.  j;  use  292 
grains  of  the  powder  to  i  quart  of  water).  Saturate 
sterile  gauze  in  this  solution  for  twenty-four  hours,  place 
in  sterile  jars,  and  seal. 

Balsam  of  Peru  Gauze.— Formula : 

Balsam  of  Peru, §iv. 

Naphthalin, oiiiss. 

The  balsam  is  sterilized  for  twenty  minutes  at  a  tem- 
perature of  212°  F.  Cut  gauze  in  strips  five  yards  long 
and  three  and  one-half  inches  wide,  sterilize,  immerse 
in  the  above  mixture,  wring  out  as  dry  as  possible,  place 
in  sterile  jars,  and  seal.  Prepare  the  gauze  before  the 
mixture  cools. 

Carbolized  Gauze. — Formula : 

Resin, §xiiiss. 

Carbolic  crystals, .  .    o  iiiss. 

Alcohol, Oiv. 

Castor  oil oiif  • 

Mix  thoroughly.  This  quantity  is  sufficient  to  impreg- 
nate thirty  yards  of  gauze.  Place  impregnated  gauze 
in  sterile  jars  and  seal. 

Gauze  Drains. — Cut  gauze  strips  one  to  three  yards 
long  and  two  to  six  inches  wide.  Cut  by  drawn  thread 
to  avoid  frayed  edges.  Turn  in  the  raw  edges.  Cervi- 
cal and  uterine  drains  are  eighteen  inches  long  and  one 
inch  wide,  with  the  edges  turned  in.  Gauze  drains  may 
be  impregnated  with  antiseptics  and  sterilized  accordingly. 

Wicking  Drains. — Material  is  string  lamp-wicking 
which  comes  in  lengths  of  several  yards  rolled  up  in 
balls.  Cut  in  lengths  of  nine  inches,  place  in  bundles  of 
four  wicks  each,  fasten  ends  with  silk,  boil  for  one-half 


40 


OPERATING    ROOM    AND    THE    PATIENT. 


hour  in  saline  solution,  place  in  jars,  sterilize,  and  seal. 
The  wicking  may  be  impregnated  with  antiseptics.  The 
wicking    drain    may    be    inclosed    in  fenestrated    green 


'  I 


■•■■I 

•■■Bl 

■■■■I 
■■■•I 
«■■■! 
■■■■I 

■  ■■■I 

OBaai 

■  ■■■J 

■  ■■■I 
aanai 
aaaai 
aaaai 
taail 


Fig.   7. — The  sterilizing  room. 


silk  protective  stitched  in  place.  These  latter  are  known 
as  "cigarette  drains."  They  are  sterilized  for  twenty 
minutes  at  a  temperature  of  212°  F. 


INSTRUMENT  AND  SUPPLY  ROOM.  4I 

Rubber  Tissue  Drains. — The  rubber  tissue  is  cut  in 
strips  two  by  three  to  six  inches,  boiled  in  water  for  five 
minutes,  preserved  in  50  per  cent,  alcohol  in  normal 
saline  solution,  or  after  boiling  it  may  be  rolled  between 
layers  of  gauze,  placed  in  jars,  and  sterilized  for  twenty 
minutes  at  a  temperature  not  higher  than  212°  F.  Heat 
will  destroy  very  light  rubber  tissue  if  prepared  in  this 
way. 

Mikulicz  Drain  acts  as  a  capillary  drain  and  by  com- 
pression arrests  oozing.  It  is  simply  a  square  of  gauze, 
plain  or  medicated,  in  which,  after  it  is  placed  in  the 
cavity  to  be  filled,  are  packed,  as  in  a  bag,  strips  of  gauze 
the  ends  of  which,  as  well  as  the  corners  of  the  square 
bag,  emerge  from  the  wound. 

Cotton,  nonabsorbent,  is  prepared  by  cutting  the 
original  roll  in  half  lengthwise,  then  unrolling  each  half 
and  cutting  crosswise  into  four  sheets.  Each  sheet  is 
rolled  up,  not  very  tightly,  and  covered  with  heavy 
sheeting  material.  Sterilize  by  steam  at  a  temperature 
of  240°  F.  for  one-half  hour.  This  cotton  is  used  for  the 
outer  protection  of  wounds  and  for  padding  splints. 

Cotton,  Absorbent. — Small  pieces  are  used  on  wooden 
applicators  for  cleansing  wounds  or  applying  caustics. 
Absorbent  cotton  may  be  rolled  up  in  small  packages  and 
sterilized  for  use  in  the  operating  room. 

Lambs'  Wool  is  cut  into  convenient  sizes  (two  inches 
by  four)  for  tampons.  An  eight-inch  piece  of  cotton 
string  is  tied  around  the  middle  of  the  tampon  to  facili- 
tate its  withdrawal.  The  ends  of  the  string  should  be 
knotted  together. 

SPONGES. 
Sponges  are  made  of  gauze  in  three  sizes:  the  hand 
sponge,  eighteen  inches  square;  the  stick  sponge,   one- 
sixteenth  of  a  yard  square;  and  the  laparotomy  sponge, 
eight,  ten,  or  twelve  inches  square. 


/ 
v 


42  OPERATING    ROOM    AND    THE    PATIENT. 

Hand  sponges  are  made  of  a  single  thickness  of  gauze. 
Two  opposite  sides  are  folded  one  over  the  other  so  as  to 
lessen  the  width  of  the  gauze  two-thirds ;  the  short  sides 
of  the  resulting  rectangle  are  folded  toward  each  other 
^  and  the  end  of  one  short  side  is  inserted  into  the  end  of 
the  other  short  side  in  the  same  manner  that  one  tucks 
in  the  flap  of  an  envelope.  With  a  little  practice  sponges 
can  be  made  more  quickly  in  this  manner  than  by  sewing 
them.     They  are  put  up  in  packages  of  twenty-five. 

Stick  sponges  may  be  made  in  three  ways:  either  like 
the  hand  sponges  or  three  corners  of  the  small  square 
may  be  folded  to  the  center  and  then  rolled  into  a  ball 
which  is  held  in  shape  by  inclosing  it  with  the  fourth 
corner  (like  a  pair  of  socks  are  held  in  shape  when  rolled 
up)  or  a  small  quantity  of  absorbent  cotton  may  be 
inclosed  in  a  three-inch  square  of  gauze  held  in  shape 
by  stitching.  They  are  put  up  in  packages  of  fifty. 
Smaller  stick  sponges  are  made  of  gauze  for  use  in  small 
cavities. 

Laparotomy  sponges  are  made  in  three  sizes:  eight, 
ten,  or  twelve  inches  square.  They  are  made  of  six 
thicknesses  of  gauze,  the  edges  being  turned  in  and 
/  hemmed  so  that  there  are  no  loose  threads.  To  one 
»  corner  of  the  sponge  is  sewn  a  tape  twelve  inches  in 
length.  Twelve  laparotomy  sponges  of  the  same  size, 
the  tapes  numbered  from  one  to  twelve,  are  made  into 
a  package. 

Laparotomy  sponges  may  also  be  made  of  crash. 
Crash  wash-cloths  are  useful  for  this  purpose.  They 
should  have  the  usual  twelve-inch  tape  attached. 

Particular  care  must  be  exercised  in  counting  these 
sponges,  both  when  they  are  made  up  into  packages  and 
when  these  packages  are  opened  by  the  sponge  nurse. 
Any  inaccuracy  in  the  count  must  be  at  once  reported 
to  the  operating  room  nurse.  The  sponge  nurse  must 
be  able  to  give  the  correct  count  whenever  called  upon. 


F 


INSTRUMENT    AND    SUPPLY    ROOM.  43 

COMPRESSES. 

Compresses  are  of  a  single  thickness  of  gauze  one  yard 
square.  Two  opposite  sides  are  folded  so  as  to  overlap 
each  other  thus  turning  in  the  raw  edges  and  decreasing 
the  width  of  the  gauze  by  two-thirds,  the  other  opposite 
sides  are  then  folded  over  each  other  toward  the  center. 
Compresses  are  done  up  in  packages  of  two,  for  ward 
dressings;  three,  for  laparotomy  dressings;  and  twelve,  I 
for  general  operating  room  use. 

Laparotomy   Dressing. — This   consists   of   one   laparo-   ')v 
tomy  pad,  three  one-yard  compresses,  and  an  abdominal 
binder.     These  are  done  up  in  one  package. 

Laparotomy  pads  are  used  to  save  gauze ;  they  are 
made  by  inclosing  a  twelve  inch  square  of  nonabsorbent 
cotton  in  a  gauze  bag  or  by  filling  the  bag  loosely  with 
shredded  tissue  paper. 

Paper  Dressing.^Bags  of  gauze,  twelve  by  eight 
inches,  are  loosely  filled  with  shredded  tissue  paper. 
This  form  of  dressing  is  very  absorbent,  and  is  therefore 
very  useful  in  dressing  cases  in  which  a  large  discharge 
is  expected.     They  serve  admirably  for  vulvar  pads. 

Cleansing  of  Gauze. — All  gauze  (except  the  stick 
sponges)  which  have  not  been  used  in  septic  cases 
should  be  soaked  in  several  changes  of  cold  water  and 
stirred  occasionally  to  remove  the  blood,  then  washed 
in  running  cold  water  until  all  stains  are  removed,  rolled 
in  packages,  boiled  for  one-half  hour  in  normal  salt 
solution,  wrung  out,  and  placed  in  the  steam  sterilizer 
to  dry.  When  dry,  the  gauze  is  made  up  into  sponges 
and  compresses  and  sterilized  in  the  usual  manner. 
Laparotomy  sponges  are  cleansed  in  the  same  manner. 

BANDAGES. 

Dimensions.— Mw5/m;  7  yards  long  by  if,  2,  2^,  3, 
and  4  inches  wide.     Gauze:  8  yards  long  by  3  and  3^ 


44  OPERATING    ROOM    AND    THE    PATIENT. 

inches  wide.  Flannel:  6  yards  long  by  i^,  2,  2^,  3,  and 
4  inches  wide.  Crinolin:  6  yards  long  by  2,  2^,  3^,  and 
4  inches  wide.  Finger  bandage:  4  yards  long  by  ^  and 
f  inch  wide.  Double  roller  head  bandage:  10  yards  long 
by  1-2"  and  2  inches  wide.  Chest  or  abdominal  roller: 
10  yards  long  by  4,  6,  and  8  inches  wide.  Plaster  ban- 
~)-  dages  are  made  by  incorporating  plaster  of  Paris  in  the 
meshes  of  the  crinolin  bandage  as  it  is  rolled.  They  should 
be  kept  in  tin  boxes  in  a  dry  place.  Starch  bandages: 
usually  there  is  sufficient  starch  already  in  the  crinoline 
to  make  a  fairly  stiff  supporting  bandage.  If  not, 
powdered  starch  may  be  incorporated  in  the  meshes  of 
the  bandage  as  it  is  rolled.  They  should  be  kept  in 
tin  boxes  in  a  dry  place. 

Bandage  Box. — Bandages  may  be  made  rapidly  in 
quantities  in  the  following  manner:  A  wooden  box  one 
foot  deep,  three  feet  long,  and  wide  enough  to  accommo- 
date the  bolt  of  material  is  required.  This  box  is  fitted 
with  half  a  dozen  wooden  rollers  to  guide  the  material 
to  be  used  and  a  metal  roller  with  a  crank  attached  on 
which  to  wind  the  material.  The  number  of  yards  of 
material  required  is  wound  on  the  metal  roller  and  the 
material  is  cut  across.  The  roll  is  removed  by  with- 
drawing the  metal  roller.  This  long  roll  is  then  cut  into 
the  required  widths  by  means  of  a  "Christy"  bread  knife. 
To  steady  the  roll  while  cutting,  a  small  sized  carpenter's 
mortise  board  is  useful. 

Retractor  bandages  are  used  to  retract  the  soft  parts 
in  amputations.  They  are  two  tailed  for  amputation  of 
the  humerus  or  femur,  and  three  tailed  for  amputation 
of  the  forearm  or  leg.  They  are  made  of  several  thick- 
nesses of  unbleached  muslin  twenty  inches  long  by  eight 
inches  wide. 

T-bandages     are    mostly   used    to    hold    perineal    or 

p     vulvar   dressings   in   place;   they   may   be   modified   to 

secure  dressings  in  other  parts  of  the  body.     The  single 


INSTRUMENT  AND  SUPPLY  ROOM.  45 

T-bandage  is  made  by  sewing  a  strip  of  unbleached 
muslin  three  inches  wide  by  eighteen  inches  long  to  the 
middle  of  another  strip  four  inches  wide  by  forty  inches 
long.  The  edges  should  be  hemmed.  The  double  T- 
bandage  is  made  by  sewing  two  short  strips  to  the  middle 
of  the  long  strip.  Several  sizes  of  each  variety  should 
be  made  up. 

Triangular  bandages  are  modified  T-bandages.  The 
vertical  strip  of  the  single  T-bandage  is  made  broad  at 
the  base  and  triangular  in  shape,  the  base  being  attached 
to  the  body  of  the  bandage.  This  form  of  bandage  is 
useful  in  securing  dressings  in  the  region  of  the  groin,  in 
the  gluteal  region,  and  in  the  anal  region. 

Slings. — The  sling  is  one  of  the  most  frequently  used 
of  the  compound  bandages.  A  yard  square  of  unbleached 
muslin  is  cut  diagonally  and  suffices  for  two  triangular 
slings.  The  apex  of  the  triangle  is  applied  beneath  the 
elbow,  the  portion  of  the  sling  next  the  body  is  carried 
over  the  opposite  shoulder,  the  other  portion  over  the 
shoulder  of  the  affected  side,  and  the  ends  are  fastened 
at  the  back  of  the  neck,  enough  traction  being  used  to 
insure  that  the  body  of  the  triangle  affords  equal  support 
to  the  entire  length  of  the  forearm.  The  apex  of  the 
triangle  is  secured  to  the  front  of  the  sling. 

Breast  binder.  Made  of  two  thicknesses  of  unbleached 
muslin.  It  resembles  an  armless  jacket ;  length,  i^  yards ; 
width,  back,  i6  inches;  front,  ii  inches;  under  arm,  9 
inches. 

Abdominal  binder. — Made  of  two  thicknesses  of  un- 
bleached muslin  or  one  thickness  of  Canton  flannel. 
Made  in  several  sizes,  18  inches  wide  byf,  f,  i,  i-|,  i^, 
i^  yards  long. 

Adhesive  plaster.— For  strapping  the  ankle  and  other 
joints  and  leg  ulcers  adhesive  plaster  should  be  cut  in 
long  strips  one-half  to  three-fourths  of  an  inch  in  width. 
These  strips  should  be  neatly  rolled  on  glass  or  metal 


46  OPERATING    ROOM    AND    THE    PATIENT. 

rods  six  or  eight  inches  long  for  convenient  handling. 
For  general  use  the  strips  should  be  two,  three,  and  four 
inches  in  width.  Adhesive  plaster  may  be  used  to  re- 
tain an  abdominal  dressing  in  position.  For  this  pur- 
pose, four  strips  are  used,  each  strip  ten  to  twelve  inches 
in  length  and  three  inches  wide.  One  end  of  each  strip 
is  folded  on  itself,  adhesive  surfaces  together,  for  one 
inch.  This  is  to  facilitate  removal.  The  other  end  of 
each  strip  is  folded  on  itself,  adhesive  surfaces  together, 
for  a  space  of  two  inches.  Through  this  double  thick- 
ness a  triangular  cut  is  made  with  the  scissors,  and  a 
half -inch  tape  is  passed  and  knotted.  Each  tape  should 
be  long  enough,  eight  to  ten  inches,  to  admit  being  tied 
in  a  bow  knot  to  its  fellow  of  the  opposite  side  over  the 
abdominal  dressing.  Two  of  these  prepared  adhesive 
plaster  strips  are  placed  on  the  skin  well  back  on  each 
flank.  The  skin  should  first  be  dried  to  insure  thorough 
adhesion.  By  applying  straps  in  this  manner  it  is  only 
necessary  to  untie  the  tapes  when  inspecting  the  dressing. 
This  does  away  with  the  unpleasant  necessity  of  frequent 
changes  of  adhesive  plaster  and  is  more  economical  in 
retaining  dressing  in  most  parts  of  the  body.  They  are 
particularly  useful  in  Syme's  amputation  and  other  foot 
amputations  in  which  part  of  the  tarsus  is  left.  All 
adhesive  plaster  strips  should  be  scrupulously  freed  from 
ravelings.  It  is  particularly  these  threads  which  tend 
to  irritate  the  skin. 

Waxed  or  paraffin  paper  is  used  to  wrap  packages  of 
dressings,  sponges,  etc.  It  is  used  as  a  substitute  for 
oiled  silk  or  gutta-percha  tissue  in  making  pneumonia 
jackets,  protecting  covering  for  wet  dressings,  etc.  It 
is  much  cheaper  than  either  of  these  materials.  Paraffin 
is  cheaper  than  wax.  To  prepare,  spread  the  sheets  of 
paper  on  a  flat  surface,  melt  the  wax  or  paraffin,  and 
pour  it  on  the  paper;  iron  evenly  with  a  hot  flat-iron. 
The  prepared  paper  should  not  be  exposed  to  high  tem- 
peratures. 


INSTRUMENT    AND    SUPPLY    ROOM.  47 

Rubber  Goods.— The  stock  supply  of  rubber  tubing 
and  other  rubber  goods,  such  as  catheters,  stomach 
tubes,  perineal  tubes,  Esmarch  constrictors,  and  Martin 
elastic  bandages,  should  be  kept  in  a  drawer  by  them- 
selves and  liberally  sprinkled  with  powdered  sulphur. 
Treated  in  this  way,  rubber  can  be  kept  in  good  condi- 
tion for  years.  Rubber  tubing  should  not  be  kinked  nor 
should  rubber  sheeting  be  creased.  Rubber  drainage 
tubes,  cut  in  desired  lengths  from  the  stock  supply,  are 
scrubbed  with  soap  and  water,  rinsed,  boiled  in  i  per 
cent,  carbonate  of  soda  solution  for  one-half  to  one  hour, 
rinsed,  and  preserved  in  alcohol,  50  per  cent,  or  carbolic 
acid,  I  140,  in  normal  saline  solution  in  sterile,  covered 
jars.  Change  the  solutions  at  least  once  each  week. 
Rubber  dam  is  sterillized  by  boiling  for  one-half  hour  in 
soda  solution,  rinsed,  and  preserved  in  carbolic  solution, 
1:20.  Green  silk  protective  is  cut  in  strips  fourteen  inches 
long  by  two  inches  wide,  laid  between  strips  of  sterile 
gauze  of  slightly  larger  dimensions,  rolled  loosely,  and 
sterilized  in  sealed  jars  at  a  temperature  of  212°  F.  for 
twenty  minutes. 

Filiform  bougies  should  never  be  boiled.  They  are 
washed  with  soap  and  water  and  placed  in  carbolic 
solution,  I  :  100,  just  before  using.  After  using,  they  are 
washed  with  soap  and  water,  rinsed,  and  carefully  dried. 
They  should  be  kept  in  a  box  or  metal  cylinder  by  them- 
selves. 

Tourniquets  and  rubber  bandages  are  washed  with 
soap  and  water,  rinsed  in  i  :  100  carbolic,  and  rolled  up 
just  before  using.  After  using,  they  are  washed  with 
soap  and  water  and  thoroughly  dried.  They  may  be 
prepared  by  boiling  in  plain  water  for  two  minutes. 

Rubber  bolsters  are  used  in  tying  cross-sutures  in  pairs. 
They  are  one  inch  in  length  (three  inches  for  perineal 
bolsters),  cut  from  rubber  aspirating  tubing.  The  cut 
edges  should  be  rounded  with  scissors.    They  are  prepared 


48  OPERATING    ROOM    AND    THE    PATIENT. 

and  preserved  in  the  same  manner  as  rubber  drainage 
tubes.  In  addition  they  should  be  boiled  for  five  minutes 
just  before  using.  They  should  be  preserved  after  re- 
moval, cleaned  and  resterilized. 

Glass  goods  comprise  various  sized  drainage  tubes, 
catheters,  connections,  irrigation  nozzles,  syringes,  medi- 
cine droppers,  and  medicine  glasses.  They  are  sterilized 
by  boiling  in  soda  solution  and  kept  in  bichlorid,  i  :  1000, 
in  covered  glass  receptacles.  This  process  should  be 
repeated  at  least  once  each  week. 

STERILIZATION  OF  SUTURE  AND  LIGATURE  MATERIAL. 

Plain  Catgut. — The  catgut  is  wound  evenly  on  glass 
spools,  one  meter  of  catgut  on  each  spool,  and  each 
spool  placed  in  a  glycerin- jelly  jar.  Each  jar  is  then 
filled  with  absolute  alcohol,  the  cap  lightly  screwed  on, 
and  the  jars  placed,  cap  down,  in  a  two-quart  glass  jar 
and  covered  with  absolute  alcohol.  This  jar  is  then 
placed  in  a  water-bath  on  a  gas  stove  (unlighted).  A 
platform  of  wire  netting  (such  as  is  used  in  making  wire 
splints)  is  placed  at  the  bottom  of  the  water-bath,  and 
on  this  the  large  jar  rests.  The  top  of  the  jar  is  of  rubber 
and  should  fit  very  snugly.  Through  the  center  of  this 
top  runs  the  lower  tube  of  a  Dowd  condensing  apparatus. 
The  inlet  water  tube  of  the  condenser  is  connected  with  a 
water  tap  and  a  small  stream  of  water  turned  on.  The 
outlet  water  tube  is  led  into  the  sink.  The  end  of  the 
outlet  alcohol  tube  is  placed  in  a  glass  jar,  the  top  of  which 
is  covered  with  gauze  wrung  out  of  bichlorid.  This  jar 
should  be  set  at  a  distance  from  the  flame  of  the  gas  stove. 
Unless  a  large  jar  is  used  for  this  purpose,  it  may  be 
necessary  to  empty  it  two  or  three  times  during  the  hour. 
Enough  alcohol  to  cover  the  jelly  jars  should  be  left  in 
the  jar.  When  the  gas  stove  is  turned  out  and  the 
sterilization  jar  begins  to  cool,  this  alcohol  is  sucked  back 
by  the  vacuum  in  the  sterilizing  jar.     Care  must  be  taken 


INSTRUMENT    AND    SUPPLY    ROOM, 


49 


that  no  fire  is  in  the  vicinity  of  the  alcohol  until  the  entire 
apparatus  is  set  up  and  ready  to  start.  The  catgut  is 
boiled  in  the  alcohol  three  successive  times  for  one  hour 
at  intervals  of  twenty-four  hours  (fractional  sterilization). 
It  is  not  removed  from  the  sterilizer  until  the  entire 
apparatus  is  cool.     Nor  is  fresh  alcohol  added  to  the 


Fig.   8. — Dowd's  condenser. 


alcohol  bath,  except  under  the  above  conditions.  Finally 
the  small  jars  are  removed  from  the  large  jar  and  their 
caps  screwed  down  tightly. 

Chromic  Catgut  No.  i. — Plain  catgut  is  sterilized  for 
one  hour  by  the  above  method.  It  is  then  wound  from 
the  spool  on  glass  plates  thoroughly  dried  for  twenty- 
four  to  forty-eight  hours   (if  not  thoroughly  dried  the 


50  OPERATING    ROOM    AND    THE    PATIENT. 

retained  moisture  weakens  the  gut  when  subsequently 
boiled  in  and  immersed  for  twelve  hours  in  a  solution 
of  chromic  acid,  i  :  5000.  Following  this,  it  is  allowed  to 
dry  thoroughly,  wound  again  on  spools,  and  prepared  as 
plain  catgut. 

Chromic  Catgut  No.  2. — Plain  catgut  is  immersed  for 
twenty-four  hours  in  ether  or  sterilized  by  boiling  in 
alcohol  for  one  hour.  It  is  dried  for  two  days  and  then 
placed  for  thirty  hours  in  a  jar  containing  the  following 
solution : 

Bichromate  of  potassium, gr.  iss. 

Carbolic  acid, gr.  x. 

Glycerin, 5  j 

Water Oj. 

It  is  then  thoroughly  dried  and  prepared  as  plain  catgut. 

Formalin  Catgut. — Immerse  the  catgut  for  twelve  hours 
in  absolute  alcohol,  Oj ;  formalin,  (40  per  cent,),  5ij ; 
then  boil  in  this  solution  for  one-half  hour  in  the  con- 
denser. Replace  the  alcohol-formalin  solution  with 
absolute  alcohol.  Leave  the  catgut  in  this  for  twenty- 
four  hours,  then  sterilize  as  for  plain  catgut.  The 
addition  of  glycerin,  5j,  to  the  alcohol-formalin  solution 
is  useful  in  softening  the  catgut. 

Antiseptic  Catgut  No.  i. — Immerse  catgut  for  twenty- 
four  hours  in  chloroform,  i  part ;  ether,  2  parts.  Then 
place  for  twenty -four  hours  in  a  solution  of  equal  parts  of 
formalin,  alcohol,  glycerin,  and  carbolic  acid.  Finally 
preserve  in  alcohol-bichlorid,  i  :  500. 

Antiseptic  Catgut  No.  2. — Proceed  as  above,  but 
instead  of  placing  catgut  in  alcohol-bichlorid,  i  :  500, 
place  it  for  twenty-four  hours  in  a  solution  of  equal  parts 
of  water,  alcohol,  and  glycerin.  Then  preserve  in  alcohol- 
bichlorid,  I  :  5000. 

Antiseptic  Catgut  No.  3. — Immerse  for  twenty-four 
hours  in  ether;    six  hours  in  bichlorid,  i  :  1000;   preserve 


INSTRUMENT  AND  SUPPLY  ROOM.  51 

in  absolute  alcohol.  Before  using,  boil  for  one  hour 
in  95  per  cent,  alcohol. 

lodin  Catgut. — Roll  the  catgut  on  glass  spools,  immerse 
for  twelve  hours  in  ether,  then  for  eight  days  in  i  per  cent, 
iodin  and  i  per  cent,  iodid  of  potassium  in  80  per  cent, 
alcohol.  Preserve  in  this  solution.  Kangaroo  tendon 
may  also  be  prepared  in  this  way. 

Braided  Catgut. — Cut  eight  strands  of  catgut  No.  i 
of  the  required  length,  20  inches;  knot  together  at  the 
end;  sterilize  in  absolute  alcohol  for  one  hour;  then 
braid.  Finally  sterilize  the  strands  as  plain  catgut, 
placing  two  braided  sutures  in  each  small  jar. 

Kangaroo  tendon  is  sterilized  like  plain  catgut  or  it 
may  be  boiled  for  one-half  hour  in  albolin,  at  a  tempera- 
ture of  245°  F.,  then  transferred  to  absolute  alcohol  and 
sealed. 

Silk  is  boiled  on  small  spools  for  five  minutes  in  normal 
saline  solution,  and  preserved  in  a  solution  of  alcohol- 
bichlorid  (i  :  5000) ;  or  boiled  for  five  minutes  in  bichlorid, 
I  :  500,  and  preserved  in  the  same  solution.  This  latter 
process  weakens  the  silk.  Silk  will  usually  stand  but 
three  sterilizations,  so  but  small  quantities  should  be 
made  up.  Linen  thread  is  prepared  in  the  same  way  as 
silk. 

Paraffin  Silk. — ^Wind  the  silk  loosely  on  a  glass  spool, 
and  soak  for  one-half  hour  in  soft,  white  paraffin  at  a 
temperature  not  higher  than  240°  F.  Drain.  Sterilize 
by  steam  heat,  212°  F.,  fractional  sterilization. 

Silkworm  Gut. — Boil  for  ten  minutes  in  normal  salt 
solution.  Preserve  in  a  solution  of  carbolic  acid,  i  :  30 ; 
or  boil  a  sufficient  quantity  for  each  series  of  operations 
with  the  instruments. 

Horsehair. — Scrub  with  hot  water  and  green  soap. 
Rinse  thoroughly  in  plain  water,  then  in  alcohol  50 
per  cent.  Boil  for  ten  minutes  in  i  per  cent,  soda  carbo- 
nate.    Preserve  in  alcohol-bichlorid,  i  :  1000. 


52 


OPERATING    ROOM    AND    THE    PATIENT. 


Silver  Wire. — All  small  pieces  of  silver  wire  should  be 
saved,  as  the  manufacturers  allow  for  the  silver  returned. 
Is  prepared  by  boiling  for  one-half  hour  in  normal  salt 
solution. 


PERCENTAGE  TABLE. 

To  make  four  fluid  ounces  of  solution. 

y\^  of  I  per  cent,  equals       1.92  grs. ;  approximately,     i|  grs. 


i  of  I  "   ' 

'    "     2.40  ' 

2i 

i  of  I  "    ' 

3.20  ' 

3 

i  of  I  " 

4.80  ' 

4l 

i  of  I  "    ' 

'    "     6.40  ' 

6 

i  of  I  "    ' 

'    "     9.60  ' 

9 

I 

'    "    19.20  ' 

i8i 

2 

38.40  ' 

36i 

^h      "    ' 

'    "    48.00  ' 

45^ 

3 

57.60  ' 

54^ 

4 

76.80  ' 

5j. 

5 

'    "    96.00  ' 

3iss.  g 

r.  6. 

6 

115.20  ' 

3j  gr. 

55- 

7 

134.40  ' 

3ijgr. 

13- 

8 

153-60 

3ij  gr- 

33- 

10 

192.00 

3iij  gr 

2. 

Other  strengths  in  proportion. 

Thermocautery. — The  thermocautery  should  be  thor- 
oughly tested  each  operating  day.  There  should  be  an 
extra  cautery  in  case  of  accident.  Its  principal  use  in  the 
operating  room  will  be  for  the  destruction  of  mucous 
membrane  in  appendicectomy,  in  operations  upon  the 
liver  and  bile-passages,  and  in  hemorrhoid  operations. 
All  three  cautery  tips — the  point,  the  knife,  and  the 
button  should  be  in  thorough  order.  The  benzin 
chamber  of  the  cautery  should  be  replenished  and  the 
cap  screwed  on,  and  the  rubber  tube  and  bulb  attached. 
The  tip  is  held  in  a  gas  flame  until  it  becomes  a  dull  red. 
The  benzin  vapor  is  forced  through  the  cautery  by 
squeezing  the  rubber  bulb.  Care  is  taken  not  to  fill  the 
rubber  air  reservoir  too  full  or  it  may  burst.     The  benzin 


X 


INSTRUMENT    AND    SUPPLY   ROOM.  53 

vapor  must  not  be  forced  through  until  the  cautery  tip 
becomes  red.  If  this  is  done  prematurely,  the  vapor  cools 
the  tip  and  the  heating  process  has  to  be  repeated. 
Some  cauteries  are  provided  with  an  apparatus  by  which 
the  preliminary  heating  is  accomplished  through  an  extra 
tube  connecting  the  benzin  chamber,  a  stopcock  controll- 
ing the  flow  of  benzin.  From  three  to  five  minutes 
should  be  allowed  to  get  the  cautery  in  running  order. 
Once  heated,  the  rubber  bulb  should  only  be  pressed  suffic- 
iently often  to  keep  the  tip  dull  red,  dull  red  showing  the 
proper  amount  of  heat  for  cauterizing.  If  the  tip  becomes 
too  hot,  this  is  remedied  by  momentarily  pressing  the 
rubber  tube,  thus  shutting  off  the  air  from  the  air  reser- 
voir. Just  before  the  cautery  is  handed  to  the  operator,  a 
dry  sterile  towel  should  be  thrown  around  the  body  of 
the  instrument  in  such  a  manner  as  to  allow  the  operator 
to  grasp  the  instrument  without  touching  it  directly.  In 
handing  the  cautery  to  the  operator  and  in  receiving 
it  from  him,  the  nurse  should  exercise  great  care  not  to 
come  in  contact  with  the  operator.  The  heated  thermo- 
cautery should  be  kept  at  a  distance  from  the  anesthetic. 
After  use  the  tip  should  be  thoroughly  heated  and  allowed 
to  cool  slowly.  When  quite  cold,  the  tip  is  gently 
cleansed  with  gauze.  For  appendical  operations  the 
point  tip  is  most  frequently  employed;  for  hemorrhoid 
operations,  the  button  tip;  for  liver  operations  all  three 
may  prove  useful. 

Sand    Bags. — Sand   bags    (used   for    maintaining   the 

^    patient  in  the  required  position  and  for  supporting  plaster- 

of-Paris  casts  while  drying)  are  made  in  six  convenient 

sizes:   25  by  8  inches;   18  by  10;   12  by  10;   10  by  9;   12 

by  5;   20  by  15. 

Splints. — These  are  kept  in  a  small  room  adjoining  the 
anesthetic  room.  All  varieties  of  splints  and  splint 
material  should  be  in  stock.  There  should  be  a  small 
bench  and  set  of  tools  so  that  special  splints  can  be  made. 


xl^ 


CHAPTER  IV. 
THE    ANESTHETIC    ROOM. 

Anesthetist.  Selection  of  the  anesthetic.  Ether  anesthesia.  Chloro- 
form anesthesia.  Ethyl  bromid.  Nitrous  oxid.  Junker's  apparatus. 
Trendelenberg  cannula.  Anesthol.  Spinal  analgesia.  Cocain  anes- 
thesia. 

The  furniture  of  the  anesthetic  room  consists  of  the 
anesthetic  cart,  anesthetic  table,  oxygen  apparatus,  gas 
apparatus,  and  a  stool  for  the  anesthetist.  On  the 
anesthetic  table  is  placed  the  anesthetic  tray. 

The  anesthetic  cart  is  provided  with  a  long,  rubber  pad ; 
a  rubber  pillow;  small  stretcher;  and  two  medium- 
weight,  woolen  half -blankets.  The  rubber  pad  and 
pillow  are  covered  with  linen  covers.  The  blankets  are 
folded  neatly  at  the  foot  of  the  table. 

The  oxygen  apparatus  should  have  the  tube  boiled 
after  each  use,  and  fresh  sterile  water  placed  in  the  bottle. 

On  the  anesthetic  tray  are  placed  ether,  ether  drop- 
bottle,  and  ether  inhaler;  chloroform,  chloroform  drop- 
bottle,  and  chloroform  mask;  ethyl  bromid,  tongue 
forceps,  aseptic  tongue  sutures,  mouth-gag,  sponge 
forceps,  stick  sponges,  vaselin,  hypodermatic  syringe 
charged  with  a  solution  of  sulphate  of  strychnin,  gr.  -g-g-, 
aseptic  hypodermatic  needles,  an  atomizer,  unbleached 
muslin  bandages,  bandage  scissors,  safety  pins,  pus 
basin,  towels;  two  small  glasses,  one  containing  sterile 
water,  the  other  empty;  a  minim  dropper,  a  glass 
graduate,  and  the  restoratives.  These  consist  of  a 
4-ounce  bottle  of  whisky;  tablets  of  strychnin  sulphate, 
gr.  gJ-Q-;  digitalin,  gr.  y^-g-;  caffein  benzoate,  gr.  j; 
Magendie's  solution  of  morphin,  a  box  of  amyl  nitrite 

54 


THE    ANESTHETIC    ROOM. 


55 


pearls,  and  ergotol.  The  ergotol  solution  is  made  by 
adding  i  drachm  of  the  solid  extract  of  ergot  to  i  ounce  of 
a  I  :  3000  solution  of  formalin.  The  hypodermatic  dose 
is  30  minims. 


Fig.   9. — The  anesthetic  room. 


There  should  be  in  reserve  a  second  tray  completely 
equipped. 

The  chloroform  and  ether  should  be  poured  into  blue 
glass  bottles  and  a  reserve  supply  should  be  kept  in  their 
original  packages. 


56 


OPERATING    ROOM    AND    THE    PATIENT. 


The  ether  inhaler  is  prepared  by  pinning  tightly 
around  it  a  folded  towel  which  has  been  somewhat  stiff- 
ened by  folding  in  it  a  few  sheets  of  wrapping  paper. 
The  stiffened  towel  should  project  an  inch  or  so  below 
the  face  part  of  the  inhaler  and  is  intended  to  protect  the 
patient's  face  against  pressure  from  the  hard  edge  of  the 
inhaler.  In  adminstering  ethyl  bromid  a  rubber  face 
piece  should  be  used  in  place  of  the  stiffened  towel  in 


Fig.    lo. — Author's  modification  of  Dr.  George  R.   Fowler's  ether 

inhaler. 


order  to  exclude  all  air.  There  should  be  kept  in  a  con- 
venient place  fresh  hair  bags  and  clean  chloroform  mask 
covers.  The  ether  inhaler  is  washed,  dried,  a  fresh  hair 
bag  inserted,  and  a  fresh  cover  put  on  for  every  case. 
The  chloroform  mask  is  washed  and  a  fresh  cover  put  on 
for  every  case.  The  tongue  forceps,  mouth-gags,  and 
stick  sponge  holders  are  washed  and  sterilized  after  each 
case.     The  tongue  suture  is  renewed  as  often  as  used. 


THE    ANESTHETIC    ROOM.  57 

On  a  reserve  anesthetic  tray  in  the  instrument  room 
should  be  kept,  always  ready  for  use,  Junker's  apparatus 
for  chloroform  anesthesia  and  Trendelenburg  apparatus 
for  chloroform  anesthesia. 

The  anesthetist  should  don  his  gown  and  cap,  but  need 
not  put  on  his  mask  until  he  enters  the  operating  room. 
He  should  be  familiar  with  the  patient's  history  and  with 
the  condition  of  the  heart,  lungs,  and  kidneys.  He  takes 
charge  of  the  case  from  the  time  it  is  brought  to  the 
anesthetic  room  until  it  is  placed  in  charge  of  the  nurse 
who  watches  it  until  consciousness  is  regained.  He 
should  endeavor  to  inspire  the  patient  with  confidence. 
He  should  see  that  all  foreign  bodies  are  removed  from 
the  mouth  and  that  respiration  is  not  impeded  through 
constriction  of  the  neck  or  chest  by  clothing  or  dressings. 
In  catarrhal  conditions  of  the  nose  and  throat  a  pre- 
liminary spray  of  2  per  cent,  cocain  solution  should  be 
employed.  Alcoholic  patients  should  be  given  morphin 
sulphate,  gr.  ^  to  ^,  hypodermatically  fifteen  to  thirty 
minutes  before  the  anesthetic  is  begun.  Morphin  habi- 
tues should  be  given  a  dose  of  morphin  proportionate  to 
the  amount  to  which  they  have  been  accustomed.  The 
nose,  lips,  and  skin  in  the  neighborhood  should  be 
anointed  with  vaselin  to  avoid  irritation  from  the 
anesthetic.  The  eyes  should  be  protected  by  covering 
them  with  a  folded  towel.  Should,  in  spite  of  this  pre- 
caution, some  of  the  anesthetic  enter  the  eyes,  they 
should  be  irrigated  with  boric  acid  solution  as  soon  as 
practicable  and  a  compress  wet  with  boric  acid  solution 
kept  on  them.  The  patient's  head  should  be  turned  to 
one  side  and  should  be  lower  than  the  body  to  facilitate 
the  escape  of  secretions  from  the  angle  of  the  mouth  and 
the  nose.  The  position  should  not  be  forced,  and  should 
not  interfere  with  respiration.  A  fiat  pillow  may  remain 
under  the  patient's  head  to  protect  the  head  from  the 
table. 


58  OPERATING    ROOM    AND    THE    PATIENT. 

The.  anesthetist  should  call  the  operator's  attention  to 
any  deviation  from,  the  normal  course  of  anesthesia  and 
see  that  stimulation  is  promptly  administered.  He  is 
not  to  leave  the  patient  for  any  reason  unless  some  one 
is  at  hand  to  relieve  hira.  He  assists  in  placing  the 
patient  upon  the  operating  table,  and  is  then  provided 
with  a  mask  by  the  junior  nurse.  He  will  be  notified  by 
the  operator  when  to  discontinue  the  anesthetic.  Ether 
vapor  is  inflammable ;  so  care  must  be  exercised  in  using 
the  thermocautery  not  to  bring  it  near  this  anesthetic. 
The  anesthetic  should  be  discontinued  during  dilatation 
of  the  sphincter  ani  preliminary  to  operations  upon  the 
rectum.  Qtherwise  the  deep  inspirations  which  this 
procedure  occasions  would  cause  the  patient  to  become 
too  profoundly  anesthetized.  This  would  be  particularly 
dangerous  in  chloroform  anesthesia. 

The  selection  of  the  anesthetic  depends  upon  the  condi- 
tion of  the  patient  and  the  character  of  the  operation. 
The  anesthetic  which  will  be  borne  with  least  danger  and 
yet  will  permit  of  all  necessary  manipulations  in  the 
operation  is  the  one  to  be  selected.  Local  anesthesia  is 
indicated  in  operations  occupying  short  periods  of  time 
and  those  in  which  the  nerves  supplying  the  parts  can  be 
readily  anesthetized;  also  in  operations  of  longer  dura- 
tion in  which  ether  or  chloroform  is  absolutely  contra- 
indicated,  the  operation  being  upon  a  part  of  the  body 
which  is  not  controlled  by  spinal  analgesia.  Nitrous 
oxid  may  be  indicated  in  some  of  these  latter  cases.  If 
ether  or  chloroform  is  contra-indicated  either  by  the 
character  of  the  operation  or  by  the  weak  condition  of 
the  patient,  or  by  advanced  lesions  of  the  heart,  lungs, 
or  kidneys,  we  must  employ  local  anesthesia  or  spinal 
analgesia. 

Nitrous  oxid  is  the  safest  of  general  anesthetics,  but 
unfortunately  its  field  is  limited.  It  is  useful  in  short 
operations  and  in  tiding  over  the  primary  stages  of  ether 


THE    ANESTHETIC    ROOM.  59 

anesthesia.  It  may  be  employed  in  longer  operations, 
but  is  not  satisfactory  where  absolute  relaxation  of  the 
patient  is  essential.  In  cases  in  which  the  heart  muscle 
is  much  weakened  or  in  which  there  is  considerable 
difficulty  in  respiration,  it  is  not  safe  to  employ  it  alone, 
though  it  may  be  combined  with  oxygen.  As  a  pre- 
liminary to  ether  anesthesia,  it  is  thoroughly  satisfactory. 
Given  alone,  in  children,  there  is  apt  to  be  pronounced 
muscular  twitchings;  in  pronounced  anemia  there  is 
danger  of  respiratory  or  cardiac  failure ;  in  arterio- 
sclerosis there  is  danger  from  the  strain  upon  the  circu- 
latory apparatus.  These  dangers  are  considerably  les- 
sened if  oxygen  is  combined  with  it. 

Spinal  analgesia  should  only  be  employed  in  those  cases 
in  which  a  general  anesthetic  is  contra-indicated.  Anes- 
thesia can  always  be  relied  upon  up  to  the  level  of  the 
anterior  superior  iliac  spines,  and  in  many  cases  still 
higher. 

Ether  Anesthesia.  The  patient's  confidence  is  strength- 
ened by  pouring  a  small  amount  of  ether  on  the  cone  and 
holding  the  cone  a  few  inches  from  the  face,  thus  accus- 
toming him  to  the  smell.  He  is  directed  to  take  deep 
breaths  and  to  expire  freely.  The  cone  is  gradually 
approached  to  the  face  until  it  covers  the  mouth  and 
nose.  The  anesthetist's  left  hand  grasps  the  cone,  and 
one  finger  of  the  same  hand  is  hooked  under  the  jaw  to 
hold  it  forward ;  the  jaw  should  be  kept  forward  through- 
out the  anesthesia.  The  nurse  should  keep  a  finger 
constantly  upon  the  pulse.  The  patient  now  breathes 
through  the  cone.  Ether  is  added  drop  by  drop,  slowly 
at  first  and  then  more  rapidly.  If  added  too  rapidly  at 
first  the  patient  will  gag  and  struggle.  By  this  graduated 
drop  method  the  patient  passes  into  a  state  of  primary 
unconsciousness.  This  state  may  be  transitory  and  a 
state  of  unconscious  struggling  may  ensue  or  the  patient 
may  pass  directly  into  a  state  of  profound  anesthesia. 


6o  OPERATING    ROOM    AND    THE    PATIENT. 

This  primary  state  of  unconsciousness  varies.  In  alcoho- 
lics and  drug  habitues,  it  is  of  brief  duration,  while  in 
patients  profoundly  septic,  or  in  shock,  this  stage  passes 
directly  into  profound  anesthesia.  Following  the  state 
of  primary  unconsciousness,  there  is  usually  some 
unconscious  struggling.  This  is  more  marked  in  men 
than  in  women  and  is  most  severe  in  alcoholics  and  drug 
habitues.  During  this  stage  the  ether  should  be  dropped 
faster,  the  cone  pressed  firmly  over  the  mouth  and  nose, 
the  jaw  held  forward,  and  the  patient's  struggles  re- 
strained. In  restraining  the  struggling  no  greater  force 
should  be  used  than  is  absolutely  necessary.  Misguided 
efforts  in  this  direction  only  tend  to  increase  the  strug- 
gling. The  unconscious  movements  of  the  patient  should 
be  guided,  rather  than  forcibly  restrained. 

The  stage  of  excitement  gradually  subsides.  The 
convulsive  movements  become  less  and  less.  The  later 
part  of  this  stage  is  marked  by  muscular  rigidity.  Mus- 
cular relaxation  gradually  follows.  The  respirations, 
which  during  the  stage  of  excitement  have  been  irregular, 
spasmodic,  and  interrupted  by  attempts  at  speech, 
become  deep,  regular,  and  finally  stertorous.  The 
conjunctival  reflex  disappears.  The  pupil  is  midway 
between  contraction  and  dilatation  and  responds  to  light. 
The  anesthetic  is  now  established.  Should  the  anes- 
thetic be  continued  the  pupil  will  dilate,  will  not  respond 
to  light,  and  the  respirations  will  become  shallow,  marking 
the  danger  stage  of  ether  anesthesia.  Should  the  anes- 
thetic be  discontinued,  the  pupil  will  also  dilate,  but  will 
respond  to  light,  the  respiration  will  become  normal,  and 
the  patient  will  regain  the  stage  of  excitement.  Both 
these  conditions  should  be  avoided.  The  anesthetic 
having  been  thoroughly  established,  the  condition  should 
be  maintained  by  dropping  ether  in  the  cone  from  time 
to  time.  Just  enough  ether  should  be  added  to  keep  the 
pupil  midway  between  contraction  and  dilatation.     The 


THE    ANESTHETIC    ROOM.  6l 

pupil  should  respond  at  all  times  to  light.  To  insure 
against  the  patient  coming  out  of  the  anesthetic  while 
being  transferred  from  the  anesthetic  room  to  the  operat- 
ing table,  the  cone  should  be  kept  closely  applied  to  the 
face. 

With  the  patient  properly  placed  on  the  table,  the 
anesthetist  must  watch  the  respiration,  pulse,  and  pupil. 
In  the  majority  of  cases  the  pupil  will  be  the  best  guide 
to  the  degree  of  anesthesia,  but  occasionally  cases  will 
present  themselves  in  which  the  pupillary  reflex  is  lost 
early  while  muscular  rigidity  still  persists.  In  such  cases 
the  respiration  will  be  the  best  guide  as  to  the  depths 
of  the  narcosis.  The  anesthetic  must  be  continued  until 
muscular  relaxation  is  complete,  but  oxygen  should  be 
combined  with  the  ether.  In  other  cases  the  rigidity  will 
persist  even  after  the  pupils  have  ceased  to  respond  to 
light  and  the  respirations  have  become  deep  and  stertor- 
ous. Oxygen  should  be  combined  with  ether  in  these 
cases  also.  A  hypodermatic  injection  of  morphin  sul- 
phate, gr.  I,  often  aids  in  overcoming  the  rigidity.  These 
atypical  cases  are  to  be  watched  very  carefully.  In 
many  cases  the  administration  of  oxygen  with  the  ether 
will  cause  the  case  to  pursue  a  normal  course  of  anesthesia. 
From  this,  it  would  seem  that  the  cause  of  the  condition 
lies  in  an  imperfect  oxidation  of  the  ether  through 
insufficient  air-supply.  There  are  other  cases,  patients 
suffering  from  profound  sepsis,  deep  shock,  or  severe 
hemorrhage,  whose  pupils  remain  dilated  throughout, 
whose  respirations  are  shallow,  and  whose  relaxation  is 
complete,  but  whose  pulse  gains  force  under  the  stimulat- 
ing effects  of  the  ether.  Such  cases  require  very  little 
anesthetic. 

Cyanosis  may  occur  during  any  stage  of  anesthesia  and 
results  from  insufficient  air-supply.  Occurring  in  the 
early  stage  it  is  due  to  spasm  of  the  glottis  or  to  accumu- 
lation of  mucus  in  the  pharynx.     The  former  results  from 


62  OPERATING    ROOM    AND    THE    PATIENT. 

too  rapid  adrainistration  of  ether.  The  cone  should  be 
immediately  removed,  a  mouth-gag  inserted,  and  the 
tongue  pulled  forward,  but  not  forcibly.  This  is  done 
with  tongue  forceps  which  should  be  so  constructed  as 
not  to  crush  or  bruise  the  tongue.  As  soon  as  the  patient 
has  taken  two  or  three  deep  inspirations  the  cone  should 
be  replaced  and  the  administration  of  the  anesthetic 
continued.  In  the  case  of  an  accumulation  of  mucus  or 
vomited  matter  in  the  pharynx,  the  cone  is  removed,  a 
mouth-gag  inserted,  the  pharynx  sponged  out,  and  the 
anesthetic  then  continued.  Later  on,  after  anesthesia 
has  been  established,  cyanosis  may  be  caused  by  the 
administration  of  too  much  ether,  or  may  be  due  to  falling 
back  of  the  tongue,  to  accumulation  of  mucus  in  the 
pharynx,  or  rarely  to  paralysis  of  the  larynx.  In  the 
latter  event  attempts  at  respiration  will  cease.  The 
anesthetic  is  immediately  discontinued,  the  mouth-gag 
inserted,  a  suture  passed  through  the  tongue  transversely 
to  the  septum  one  to  two  inches  from  the  tip,  and  gentle 
rythmic  traction  made  upon  the  tongue,  and  the  pharynx 
sponged  out.  If  the  patient  does  not  begin  to  breathe  im- 
mediately, gentle  rhythmic  traction  on  the  tongue  is  con- 
tinued, the  head  of  the  table  lowered,  oxygen  is  admin- 
istered; strychnin  sulphate,  gr.^V-  and  atropin  sulphate, 
gr.  -^-Q,  administered  hypodermatically ;  the  sphincter 
ani  widely  dilated,  and  artificial  respiration  begun  and 
continued  until  breathing  is  reestablished  or  until  thirty 
minutes  after  cardiac  pulsations  have  -  ceased.  The 
anesthetist  should  attend  to  the  mouth-gag,  tongue,  jaw, 
and  pharynx;  a  nurse  should  hold  the  oxygen  tube  in 
place ;  two  assistants,  one  at  each  side  should  keep  up  the 
artificial  respirations,  a  third  assistant  should  dilate  the 
sphincter ;  a  second  nurse  should  administer  the  hypoder- 
matic stimulation ;  a  third  nurse  should  bring  the  faradic 
battery,  connect  the  electrodes,  moisten  them,  and  place 
one  on  the  lateral  region  of  the  neckand  the  other  on  the 


THE    ANESTHETIC    ROOM.  63 

epigastrium,  the  second  electrode  should  be  moved  over 
the  chest.  It  is  only  by  quick,  combined,  and  pro- 
tracted efforts  that  these  cases  of  respiratory  paralysis 
can  be  saved.  The  premonitory  signs  are  not  marked. 
The  patient  is  not  often  seemingly  deeply  anesthetized. 
The  respirations  stop  suddenly,  the  patient  gives  a  gasp 
or  two  and  then  is  quiet,  the  heart  action  continues,  and 
cyanosis  becomes  marked. 

There  may  be  a  moderate  degree  of  persistent  cyanosis 
due  to  imperfect  oxidation  of  the  ether.  This  is  remedied 
by  combining  oxygen  with  the  ether.  Such  cases  should 
be  carefully  watched. 

The  condition  of  the  blood  in  the  field  of  operation  is  a 
guide  to  the  operator  of  the  administration  of  the  anes- 
thetic. Should  the  blood  become  dark,  he  will  call  the. 
anesthetist's  attention  to  the  fact.  Should  the  patient 
be  manifestly  under  the  influence  of  the  anesthetic,  the 
ether  should  be  withdrawn  and  oxygen  administered 
until  the  blood  regains  its  normal  color.  Should  the 
patient  be  manifestly  not  under  the  anesthetic,  more  air 
or  oxygen  should  be  given  with  the  anesthetic.  An 
experienced  operator  will  know  intuitively,  aside  from 
the  information  given  him  by  the  anesthetist,  when  the 
patient  is  in  danger. 

Circulatory  failure  rarely  occurs  with  ether.  When  it 
does  occur,  there  is  usually  a  premonitory  acceleration 
and  weakening  of  the  pulse.  This  condition  should  be 
combated  by  the  administration  of  as  small  an  amount 
of  ether  as  possible  combined  with  oxygen;  strychnin 
sulphate,  gr.  ^,  repeated,  if  necessary;  whisky  one 
syringeful  after  another  at  two  minute  intervals  until 
the  pulse  responds ;  ergotol  mxxx  given  when  the  pulse 
first  begins  to  flag;  all  these  alone  or  combined  may 
be  useful.     Rarely  acute  cardiac  dilatation  will  occur. 

Chloroform  Anesthesia. — Chloroform  vapor  is  more 
irritating  than  ether  vapor ;  so  a  liberal  amount  of  vaselin 


64  OPERATING    ROOM    AND    THE    PATIENT. 

must  be  used  on  the  lips,  nose,  and  neighboring  skin. 
It  will  be  found  advantageous  as  a  routine  measure  to 
spray  the  nose  and  pharynx  with  lo  per  cent,  cocain 
solution.  This  seems  to  counteract  in  part  the  dangerous 
effects  of  chloroform  narcosis.  The  Esmarch  mask  is 
held  a  few  inches  from  the  patient's  face  and  chloroform 
dropped  slowly  upon  it.  The  mask  is  slowly  brought 
nearer  the  face,  but  not  in  contact  with  it,  still  slowly 
dropping  the  chloroform.  An  abundance  of  air  should  be 
allowed  at  all  times.  If  the  progress  is  slow  the  patient 
will  go  under  the  anesthetic  without  a  struggle.  If  the 
process  is  hastened,  there  will  be  struggling,  but  the  effect 
of  chloroform  in  concentrated  form  is  so  powerful  that 
when  it  is  "pushed"  the  anesthetization  becomes  profound 
almost  immediately.  Such  a  procedure  is  dangerous. 
Anesthesia  should  be  gradually  produced.  The  skin 
becomes  somewhat  pale,  the  reflexes  abolished,  there  is 
a  slight  accumulation  of  mucus  in  the  pharynx,  the  pupil 
is  midway  between  dilatation  and  contraction,  the  respi- 
rations moderate  in  depth  and  frequency.  Altogether, 
the  patient  presents  a  much  more  pleasing  picture  than 
when  ether  is  employed. 

The  stage  of  excitement  is  shorter  with  chloroform 
than  with  ether  and  is  rarely  marked.  The  pupillary 
reflex,  general  relaxation,  respiration,  and  pulse  must  be 
carefully  watched.  Respiratory  failure  is  not  common  as 
a  primary  complication.  Alcoholics,  however,  may  take 
chloroform  quite  as  badly  as  they  do  ether  and  the  same 
cyanotic  conditions  develop.  They  are  to  be  treated  in 
the  same  way.  No  matter  how  troublesome  the  patient, 
chloroform  anesthesia  must  not  be  "pushed."  When 
cardiac  failure  complicates  chloroform  anesthesia,  respi- 
ratory failure  quickly  follows  or  is  synchronous  with  it. 
The  skin  becomes  blanched,  the  heart  stops,  perhaps 
gives  a  throb  or  two  and  then  stops  again.  There  is  no 
warning.     Respiration  may  continue  for  a  few  minutes 


THE    ANESTHETIC    ROOM.  65 

and  then  ceases.  In  the  rare  cases  in  which  respiratory 
failure  precedes  circulatory  failure  some  hope  is  held  out 
for  restoring  the  patients,  but  in  true  circulatory  failure 
the  hope  for  a  successful  issue  is  a  very  faint  one.  Never- 
theless the  same  procedure  should  be  gone  through  with  as 
has  been  described  under  ether  anesthesia.  Opening  the 
pericardium  and  massaging  the  heart  has  not  met  with 
success  in  our  hands.  Should  the  patient  revive  and  it  be 
deemed  expedient  to  proceed  with  the  operation,  ether 
should  be  substituted  for  chloroform.  It  will  be  found 
advantageous  in  all  cases  to  combine  oxygen  with  the 
chloroform.  To  facilitate  this,  the  oxygen  tube  is  pinned 
to  the  inside  of  the  chloroform  mask. 

Ethyl  bromid  is  useful  as  a  precedent  anesthetic  to 
ether  especially  in  alcoholics.  The  amount  necessary  to 
produce  anesthesia  varies  according  to  the  weight  of  the 
patient.  Patients  weighing  one  hundred  pounds  or  under 
require  one  to  two  drachms ;  patients  weighing  under  one 
hundred  and  fifty  pounds  require  two  drachms ;  patients 
weighing  over  one  hundred  and  fifty  pounds  require  two 
to  three  drachms.  It  must  be  given  without  the  admix- 
ture of  air.  It  should  not  be  employed  in  young  children, 
the  aged,  or  in  patients  suffering  from  sepsis  or  shock. 

The  mode  of  administration  is  as  follows :  The  required 
amount  is  poured  into  a  small  graduate.  The  ether  inhaler 
is  placed  close  to  the  patient's  face  and  the  patient 
is  told  to  breathe  deeply  through  it.  After  two  or  three 
deep  breaths  have  been  taken,  the  ethyl  bromid  is  poured 
into  the  cone  through  the  slit  in  its  side,  and  the  slit 
immediately  closed.  With  the  next  inspiration,  the 
patient  inhales  all  of  the  ethyl  bromid  and  becomes 
immediately  anesthetized.  There  is  usually  a  general 
convulsive  muscular  contraction,  following  which  there  is 
general  relaxation  and  abolishment  of  all  but  the  pupil- 
lary reflex.  The  breathing  is  deep  and  stertorous,  the 
pulse  is  accelerated,  and  the  face  becomes  cyanosed.     In 

5 


66  OPERATING    ROOM    AND    THE    PATIENT. 

from  thirty  to  forty-five  seconds  the  slit  in  the  cone  is 
opened  and  ether  anesthesia  produced  by  the  constant 
drop  method.  It  will  only  be  necessary  to  repeat  the 
administration  of  ethyl  bromid  in  those  cases  in  which 
iit  is  not  possible  to  keep  the  cone  in  close  contact  with  the 
face  and  exclude  the  air.  By  this  method  surgical 
anesthesia  should  be  complete  in  seven  minutes,  generally 
in  from  three  to  five  minutes.  The  anesthetic  effect  of  the 
ethyl  bromid  is  transitory  and  is  only  intended  to  abridge 
the  primary  stage  of  ether  anesthesia.  The  smell  of  the 
drug  persists  in  the  breath  for  about  twenty-four  hours, 
and  being  of  a  garlic  odor  is  disagreeable  to  some  patients. 

Nitrous  Oxid  and  Oxygen. — The  nitrous  oxid  apparatus 
devised  by  Bennett  is  the  one  most  employed  in  this 
country.  The  average  time  for  the  production  of  anes- 
thesia is  about  two  minutes.  The  amount  of  oxygen 
varies  with  the  reaction  of  the  patient  to  the  nitrous  oxid. 
Nitrous  oxid  is  administered  pure  at  first  until  slight 
stertor  is  developed.  Then  oxygen  is  admitted  in  suffi- 
cient amount  to  prevent  further  stertor.  The  color 
should  be  natural,  the  pupils  contracted,  the  conjunc- 
tiva insensitive  and  the  muscles  relaxed.  Should  stertor 
and  cyanosis  or  muscular  twitchings  develop  more  oxy- 
gen must  be  admitted.  Symptoms  of  excitement  call 
for  more  oxygen.  It  may  happen  that  even  the  admis- 
sion of  all  the  oxygen  possible  will  not  be  sufficient  to  pre- 
vent stertor,  cyanosis,  etc.  In  such  cases  the  face  piece 
is  to  be  removed  from  time  to  time.  In  this  way  satis- 
factory anesthesia  can  be  maintained  for  fifteen  to 
twenty  minutes.  Nausea  may  occur  after  prolonged 
nitrous  oxid  and  oxygen  anesthesia. 

Nitrous  oxid  and  ether  is  a  very  satisfactory  method  of 
anesthesia.  The  gas-bag  is  filled  and  the  ether  compart- 
ment is  saturated.  The  patient  first  breathes  air  for 
two  or  three  deep  breaths,  then  the  gas  is  turned  on  and 
inhaled  and  expired  through  the  valves.     When  about 


THE    ANESTHETIC    ROOM. 


67 


one-half  of  the  gas  in  the  bag  has  been  used  in  this  way 
the  valves  are  turned  so  that  the  patient  breathes  in  and 
out  of  the  bag.  Nitrous  oxid  anesthesia  should  now  be 
complete.  The  ether  is  now  turned  on  so  that  the 
patient  breathes  gas  mixed  with  ether.  No  air  should 
be  given  until  ether  anesthesia  is  complete.  This  takes 
about  three  minutes.  Anesthesia  may  be  continued  by 
the  addition  of  small  quantities  of  ether  as  required  and 
the  admission  of  oxygen.  It  is  our  practice,  however,  to 
change  to  our  own  inhaler  as  soon  as  the  anesthesia  is 
established  and   continue   the  anesthetic  with  it.     The 


Fig.    II. — Junker's  apparatus. 


change  should  be  made  quickly  and  the  inhaler  should 
have  been  saturated  with  ether  just  previous  to  the 
change. 

Junker's  Apparatus. — This  is  very  clearly  shown  in  the 
illustration.  The  two  catheters  are  inserted,  one  in  each 
nostril,  until  the  level  of  the  pharynx  is  reached.  A 
safety  pin  is  then  passed  through  each  catheter  to  mark 
off  the  proper  distance  to  which  they  are  to  be  reinserted 
in  case  of  removal.  A  narrow  piece  of  adhesive  plaster 
wound  once  around  the  tubes  and  fastened  to  each  cheek 
serves  to  keep  the  tubes  in  place.     In  coupling  up  the 


68  OPERATING    ROOM    AND    THE    PATIENT. 

apparatus  it  is  necessary  that  the  leading-to  tube,  the 
tube  by  which  air  is  forced  through  the  chloroform,  be 
properly  attached;  otherwise  chloroform  liquid  instead 
of  chloroform  vapor  will  be  forced  through  the  catheter 
and  will  suffocate  the  patient.  After  testing  the  appara- 
tus to  insure  its  proper  assembling  it  is  customary  lightly  to 
pack  the  chloroform  receptacle  with  lambs'  wool  to  still 
further  guard  against  spray  instead  of  vapor  being  forced 
through  the  catheter.     The  apparatus  is  useful  in  opera- 


Fig.    12. — Trendelenburg  cannula. 

tions  in  which  anesthesia  by  the  ordinary  methods  would 
bring  the  anesthetist  in  the  way  of  the  operator. 

The  Trendelenburg  cannula  is  useful  in  operations  about 
the  larynx  and  pharynx.  The  tube  is  introduced  through 
a  tracheotomy  opening,  and  the  little  air-bag  around  the 
tube  gently  inflated.  This  prevents  blood  descending 
alongside  the  tube.  Chloroform  is  given  drop  by  drop 
on  the  gauze  covered  cannula  in  the  usual  way. 

Anesthol  was  first  used  by  Prof.  Willy  Meyer  October 
15,   1898.     It  is  a  chemic  combination  of  ether   (47.10 


THE    ANESTHETIC    ROOM.  69 

per  cent.)  chloroform  (35.89  per  cent.),  and  ethyl  chlorid 
(17  per  cent.),  having  a  specific  gravity  of  1.045  ^^^  ^ 
boiling  point  of  104°  F. 

Anesthol  is  administered  drop  by  drop.  An  Esmarch 
mask  is  used  covered  with  several  layers  of  gauze  and  a 
piece  of  oiled  silk.  An  aperture  the  size  of  a  silver 
dollar  is  cut  in  the  oiled  silk.  There  is  no  struggling. 
If  the  anesthetic  is  pushed  too  rapidly  the  patient  will 
turn  pale  and  respiration  will  become  very  shallow  or 
apparently  cease.  The  heart  does  not  seem  to  be  in- 
fluenced. As  soon  as  the  second  stage  of  general  anes- 
thesia is  reached  one  or  two  drops  every  two  or  three 
seconds  will  suffice  to  keep  the  patient  under.  The 
administration  of  the  drops  must  be  regularly  continued. 
Anesthol  does  not  seem  to  affect  the  circulation.  Oc- 
casionally the  respirations  will  become  very  shallow 
during  the  administration.  If  this  occurs  the  with- 
drawal of  the  anesthetic  is  sufficient  to  cause  the  patient 
to  breathe  more  deeply.  The  appearance  of  the  patient 
is  one  of  light  slumber. 

With  the  relation  between  the  boiling  point  of  the 
anesthetic  and  the  internal  body  temperature  so  close  as 
they  are  in  anesthol  it  holds  true  that  a  patient  will  come 
out  of  the  anesthetic  very  quickly,  and  in  many  cases  the 
reflexes  will  not  be  lost  at  any  time  during  the  anesthesia. 
To  prevent  this  it  is  desirable  to  give  a  hypodermatic 
injection  of  morphin  (gr.  ^  or  -J)  one-half  hour  before 
anesthesia. 

When  under  anesthol,  the  respirations  are  slow,  quiet, 
and  full  without  being  stertorous.  The  color  is  natural 
and  the  pupils  slightly  contracted  (morphin  having  been 
administered  previously),  the  pulse  slow,  full,  and  regular. 
There  is  no  excess  of  mucous  secretions.  Muscular 
relaxation  is  complete.  The  return  to  consciousness 
is  prompt.  There  is  vomiting  in  only  a  very  few  cases 
and,  as  a  rule,  this  is  not  so  distressing  as  after  ether 
anesthesia. 


70  OPERATING    ROOM    AND    THE    PATIENT. 

Spinal  Analgesia. — By  this  method  immunity  from  pain 
may  be  reHed  upon  in  all  operations  up  to  the  level  of 
Poupart's  ligament.  In  the  vast  majority  of  cases  there 
will  also  be  immunity  from  pain  in  operations  up  to  the 
level  of  the  umbilicus  anteriorly  and  somewhat  higher 
posteriorly.  Beyond  this,  analgesia  can  not  be  relied 
upon.  In  rare  cases,  it  may  extend  as  high  as  the  second 
rib.  In  cases  in  which  this  higher  area  of  analgesia  is 
obtained  the  Trendelenburg  position  may  be,  in  part, 
responsible.  Nor  is  analgesia  at  all  satisfactory  in  intra- 
abdominal operations.  This  is  particularly  true  in 
inflamed  conditions  of  the  peritoneum. 

During  and  following  the  period  of  analgesia  numerous 
unpleasant  symptoms  may  occur.  That  these  are  not 
due  to  the  cocain  alone  seems  to  be  proven  by  the  fact  that 
the  same  symptoms  are  equally  marked  whether  a  large 
or  small  dose  of  cocain  be  employed  as  well  as  in  cases  in 
which  antipyrin,  tropacocain,  or  chloretone  was  used, 
and  in  one  case,  vertigo,  pallor,  cold  sweat,  sighing 
respiration;  rapid,  weak  pulse;  dry  cough,  nausea,  and 
vomiting  occurred  before  any  cocain  had  been  introduced 
and  after  but  a  few  drops  of  cerebrospinal  fluid  had  been 
withdrawn.  In  addition  to  these  unpleasant  symptoms 
there  may  occur:  headache,  chills,  and  involuntary 
defecation  and  urination.  On  the  other  hand,  the  course 
of  analgesia  may  be  quite  free  from  all  unpleasant 
symptoms,  or  at  most  a  rise  of  temperature  and  headache 
may  develop  a  few  hours  afterward. 

In  order  to  avoid  respiratory  or  circulatory  depression 
it  is  customary  to  give  strychnin  sulphate,  gr.  -^,  hypoder- 
matically  fifteen  minutes  before  the  spinal  injection. 

Vertigo  is  seldom  noticed.  Nausea  occurs  in  about 
one-half  of  the  cases  five  to  ten  minutes  following  the 
injection.  Actual  vomiting  takes  place  in  about  one- 
third  of  the  cases.  It  rarely  lasts  longer  than  two  minutes. 
Dry  retching  will  exceptionally  occur,  but  is  not  persist- 


THE    ANESTHETIC    ROOM.  7 1 

ent.  Some  cases  seem  to  be  relieved  of  their  nausea  and 
vomiting  is  prevented  by  swallowing  a  cup  of  hot  coffee 
when  the  first  symptoms  appear.  Headache  occurs  in 
two-thirds  of  the  cases,  usually  frontal  in  character  and 
may  be  mild  or  severe.  It  comes  on  three  or  four  hours 
after  the  injection.  The  severe  form  may  become 
general  and  last  for  from  twenty-four  to  forty-eight 
hours.  Treatment  is  of  slight  avail.  Nitroglycerin 
seems  to  be  the  most  efficient  drug  in  this  connection. 
Rise  of  temperature  is  a  fairly  constant  symptom.  It 
occurs  from  three  to  eight  hours  following  the  injection. 
Usually  the  temperature  does  not  rise  higher  than  ioi° 
to  102°  F.  and  rapidly  returns  to  normal.  Involuntary 
micturition  and  defecation  occur  in  a  few  cases.  Some- 
times the  patients  are  aware  of  these  occurrences  and 
sometimes  not.  Pronounced  chills  are  seldom  observed. 
Pallor,  cold  sweat,  and  sighing  respiration  have  only  been 
noted  in  cases  in  which  there  was  also  present  nausea, 
vomiting,  and  rapid,  weak  pulse.  All  of  these  unpleasant 
symptoms  are  lessened  by  the  preliminary  hypodermatic 
use  of  strychnin  sulphate,  gr.  ^-^. 

RULES  FOR  MAKING  THE  INJECTION.* 

1.  The  instrument  em.ployed  may  be  a  fine  aspirating 
needle  and  an  ordinary  solid-piston  hypodermatic  syringe. 
A  special  needle  inclosed  by  a  cannula  is  a  convenience 
under  some  circumstancs,  and  a  glass  barrel  and  asbestos- 
piston  syringe  add  a  nicety  to  the  procedure.  These 
should  be  sterilized  by  boiling. 

2.  Give  the  patient  a  hypodermatic  injection  of  -^-^ 
grain  of  sulphate  of  strychnin,  a  quarter  of  an  hour 
before  the  injection,  and  have  a  glass  of  hot  water  or  a 
cup  of  hot  coffee  ready  to  administer  should  nausea  occur. 

3.  Place  one  or  more  tablets  of  hydrochlorate  of  cocain, 

*  G.  R.  Fowler,  "Medical  Review  of  Reviews,"  April    1901. 


72  OPERATING    ROOM    AND    THE    PATIENT. 

according  to  the  character  and  site  of  the  proposed 
operation,  in  a  steriHzed  teaspoon  or  other  convenient 
article,  crush  them,  and  pour  on  a  few  drops  of  chloro- 
form to  form  a  paste  (Bainbridge's  method  of  sterilization 
of  cocain).  When  the  chloroform  has  evaporated,  add 
from  15  to  30  minims  of  boiled  water,  according  to  the 
amount  of  cocain  employed.  Half  a  grain  is  the  usual 
quantity  used. 

4.  A  soap-and-water  and  alcohol  cleansing  of  the  skin 
of  the  back,  with  proper  isolation  by  means  of  clean 
towels  and  surgically  clean  hands  answer  the  require- 
ments of  asepsis. 

5.  The  position  of  the  patient  may  be  either  one  of 
three  postures:  (a)  The  sitting  position  upon  the  edge 
of  the  operating  table,  leaning  well  forward,  (b)  The 
semiprone  or  Sims'  position,  (c)  The  left  lateral  de- 
cubitus, with  both  thighs  flexed  upon  the  abdomen,  the 
shoulders  and  head  thrown  forward,  and  a  cushion  placed 
between  the  left  loin  and  the  table  to  prevent  lateral 
deviation  of  the  spine  in  the  lumbar  region. 

6.  The  highest  point  of  the  crest  of  the  ilium  is  to  be 
identified,  and  upon  a  line  straight  across  the  back  from 
this  point  will  be  found  the  fourth  lumbar  vertebra. 
The  depression  immediately  above  this  or  the  one  below, 
if  this  is  more  easily  identified,  may  be  utilized  for  the 
injection. 

7.  Select  a  point  about  half  an  inch  to  the  right  of  the 
middle  of  the  space  chosen  and  here  introduce  the  needle. 
A  preliminary  injection  of  a  few  drops  of  cocain  solution, 
first  in  the  skin  itself  and  then  into  the  depths,  renders  the 
patient  less  liable  to  start  when  the  needle  is  introduced, 
and  a  slight  dimple  made  with  the  point  of  a  rather  blunt 
scalpel  is  an  additional  precaution  against  infection. 

8.  Enter  the  needle  at  the  point  where  the  hypoder- 
matic puncture  has  been  made  and  direct  its  course  in  such 
a  manner  that  its  point  reaches  the  spinal  column  in  the 


THE    ANESTHETIC    ROOM.  73 

median  line.  A  very  little  practice  will  enable  the  opera- 
tor to  estimate  the  angle  necessary  to  hold  the  needle  to 
effect  this.  Pass  the  needle  slowly,  and  if  the  angle  has 
been  correctly  estimated  and  the  middle  of  the  space 
between  the  spinal  processes  properly  identified,  the 
resistance  to  its  passage  will  be  but  slight,  until  it  reaches 
the  interspinous  ligament,  when  a  decided  and  appreciable 
increase  in  resistance  will  be  felt.  Should  it  strike  bone, 
withdraw  partially  or  entirely  and  change  its  course.  It 
will  be  more  likely  to  strike  the  upper  than  the  lower 
lamina.  Once  it  has  entered  the  spinal  canal,  unless  its 
lumen  has  become  blocked,  the  cerebro-spinal  fluid 
appears  flowing  from  the  needle  in  clear  or  slightly 
blood-tinged  drops. 

9.  Screw  upon  the  needle  the  hypodermatic  syringe 
previously  charged  with  the  cocain  solution  and  inject 
slowly.  Leave  the  needle  in  situ  with  the  syringe 
attached  for  half  a  minute,  so  as  to  prevent  leakage  from 
the  puncture,  and  then  withdraw.  Pencil  a  little  collo- 
dion over  the  point  of  puncture  and  cover  with  a  small 
piece  of  adhesive  plaster. 

10.  Test  for  the  analgesia  once  a  minute,  commencing 
in  the  soles  of  the  feet,  with  a  needle.  Simple  touch 
sensation  is  not  abolished ;  the  patient  must  complain  of 
actual  pain,  otherwise  analgesia  is  established.  In  the 
average  case,  numbness  and  formication  in  the  feet 
occur  in  from  one  to  three  minutes,  and  analgesia  in  the 
lower  extremities  in  from  four  to  six  minutes.  In  from 
seven  to  fifteen  minutes  the  analgesia  has  reached  to 
varying  points  between  the  umbilicus  and  the  level  of  the 
fourth  rib  in  the  line  of  the  nipple.  In  some  of  the  cases 
in  which  the  point  was  noted,  it  appeared  to  reach  a 
higher  level  posteriorly  than  anteriorly.  The  analgesia 
lasts  from  thirty  minutes  to  an  hour  and  a  half,  according 
to  the  quantity  of  cocain  employed,  and  recedes  from 
above  downward. 


74  OPERATING    ROOM    ATSTD    THE    PATIENT. 

Cocain  Anesthesia. — Hydrochlorate  of  cocain  is  em- 
ployed in  -I,  2,  and  4  per  cent,  aqueous  solution  either 
alone  or  combined  with  minute  quantities  of  morphin. 
Rarely  is  a  4  per  cent,  solution  necessary.  Schleich's 
solution  may  be  made  from  tablets  or  may  be  prepared, 
according  to  the  following  formulas : 

No.  I.  (Strong). 

Cocain  hydrochlorate, gr.  j. 

Morphin  hydrochlorate, gr.  ^. 

Sodium  chlorid, gr.  j. 

Sterile  water, 5  j- 

No.  2.  (Medium). 

Cocain  hydrochlorate, gr.  ^. 

Morphin gr-  i- 

Sodium  chlorid, gr.  j. 

Sterile  water §  j. 

No.  3.  (Weak). 

Cocain  hydrochlorate, gr.  2^^. 

Morphin  hydrochlorate, gr.  ■^^. 

Sodium  chlorid gr.  j. 

Sterile  water, §  j. 

When  possible  the  blood-supply  of  the  part  should  be 
arrested  in  order  to  maintain  the  local  effect  of  the 
cocain.  This  is  accomplished  in  the  case  of  the  extremi- 
ties by  means  of  an  Esmarch  constrictor.  In  case  of  the 
fingers  or  toes  by  constricting  the  base  of  the  member  with 
a  small  rubber  elastic  catheter. 

Following  the  usual  aseptic  preparations  a  hypoder- 
matic syringe  is  filled  with  the  required  solution  and  the 
needles  attached.  The  strength  of  solution  required  for 
skin  incisions  is  usually  i  per  cent. ;  for  deeper  dissections, 
^  per  cent.  For  anesthetizing  nerve  trunks  a  few  drops 
of  a  2  or  4  per  cent,  solution  is  used.  In  eye  operations 
the  lids  are  everted  and  a  few  drops  of  4  per  cent,  solution 
allowed  to  flow  over  the  conjunctiva. 

In  anesthetizing  the  skin  by  the  infiltration  method, 
the  needle  is  introduced  into  the  substance  of  the  skin  and 
a  few  drops  of  the  solution  injected, -^enough  to  raise  a 


THE    ANESTHETIC    ROOM.  75 

white  wheal.  The  needle  is  then  pushed  farther  along  the 
proposed  line  of  incision,  still  in  the  substance  of  the  skin, 
and  a  second  wheal  raised  which  shall  overlap  the  first. 
This  process  is  repeated  until  the  entire  line  of  the 
proposed  incision  has  been  anesthetized,  it  being  neces- 
sary to  withdraw  and  reinsert  the  needle  several  times. 
The  skin  is  tested  for  anesthesia  with  the  point  of  the 
needle  or  with  the  knife,  and,  as  soon  as  this  is  established, 
usually  in  less  than  two  minutes,  the  skin  incision  is 
made.  If  deeper  dissection  is  necessary,  injections  of 
^  per  cent,  solution  may  be  made  into  the  surrounding 
tissue,  or,  as  in  hernia  operations,  the  main  nerve  trunk 
supplying  the  parts  may  be  anesthetized  by  injection  of  a 
2  or  4  per  cent,  solution.  As  the  period  of  anesthesia  is 
variable,  it  is  well  to  proceed  with  the  operation  as 
speedily  as  possible  and  so  obviate  the  need  for  renewed 
"anesthetic.  The  amount  of  cocain  employed  should  be 
noted  and  not  more  than  i  grain  be  injected  into  tissues 
in  which  the  blood-supply  is  not  under  control.  Rarely 
will  it  be  necessary  to  use  this  amount.  In  operations  in 
which  constriction  is  employed,  the  constriction  should  be 
intermittently  removed  at  the  close  of  the  operation  in 
order  to  avoid  throwing  a  large  amount  of  cocain  rapidly 
into  the  general  circulation. 

General  effects  from  the  cocain  will  be  noted.  The 
patient  talks  quite  freely.  Should  the  heart-action  be 
quickened  and  the  pupils  dilate,  caffein  and  strychnin  will 
be  found  useful.  A  cup  of  strong,  hot  coffee  often  makes 
these  patients  quite  comfortable. 

Cocain  solutions  should  preferably  be  freshly  prepared. 
This  is  easily  done  by  Bainbridge's  method.  A  known 
quantity  of  the  crystals  or  a  tablet  is  ground  into  a  fine 
powder  in  a  sterile  spoon.  To  this  is  added  a  few  drops  of 
chloroform,  and  a  paste  made  by  thoroughly  mixing  the 
two.  The  chloroform  soon  evaporates.  A  sufficient 
quantity  of  sterile  water  is  then  added  to  make  the 
strength  of  the  solution  required. 


CHAPTER  V. 
THE  PATIENT. 

General  preparation;  mental  condition;  blood;  heart  and  lungs; 
kidneys;  skin;  bowels;  diet.  Local  preparation;  general  directions; 
head;  face;  neck;  thorax;  abdomen;  extremities;  body  cavities; 
mouth;  nose  and  pharynx;  esophagus  and  stomach;  small  and  large 
intestine;  rectum;  urethra  and  bladder;  vagina.  Preparation  just 
previous  to  leaving  for  anesthetic  room;  clothing;  bladder;  stimula- 
tion. Position  of  the  patient  for  various  operations.  Preparation 
of  operative  field  in  the  operating  room.  Duties  of  House  Surgeon; 
of  Assistant  House  Surgeon;  disinfection  of  the  hands.  Application 
of  dressings. 

The  general  preparation  of  the  patient  begins  from  the 
time  he  is  admitted  by  the  house  surgeon.  Patients 
should  be  received  in  such  a  manner  as  to  maintain,  and 
indeed  increase,  their  confidence  in  a  successful  solution 
of  their  trouble.  They  should  be  placed  at  a  distance 
from  patients  likely  to  complain,  or  whose  condition 
would  discourage  them.  Nervous  patients  should  be 
insured  a  good  rest  during  the  night  prior  to  the  operation 
by  the  administration  of  a  sedative,  preferably  a  com- 
bination of  the  bromids.  Emergency  cases,  of  course,  are 
prepared  for  immediate  operation;  other  cases,  with  the 
exception  of  laparotomy  cases,  require  twenty-four  hours' 
preparation;  laparotomy  cases  require  forty-eight  hours' 
preparation.  Any  concomitant  disease  should  receive 
appropriate  treatment. 

An  examination  of  the  blood  should  be  made  in  all  cases 
of  chronic  septic  conditions  as  well  as  in  acute  infections, 
hemorrhage  cases,  and  cases  presenting  signs  of  anemia. 
The  examination  should  consist  of  a  red-cell  count,  a 
white-cell  count,  a  differential  white-cell  count,  and  an 

76 


THE    PATIENT.  77 

estimation  of  the  percentage  of  hemoglobin.  Should  the 
latter  be  below  50  per  cent.,  it  should  be  increased,  if 
possible,  before  the  operation.  A  stained  specimen 
should  be  prepared  for  the  examination  of  the  attending 
surgeon. 

An  examination  of  the  heart  and  lungs  is  made  by  both 
the  house  surgeon  and  the  anesthetist  and  their  findings 
compared.  Any  deviation  of  the  normal  is  reported  to 
the  operator  in  time  to  allow  of  possible  change  in  the 
preparation  for  operation. 

The  Kidneys. — Immediately  following  the  first  bath  the 
patient  is  asked  to  urinate.  Before  procuring  a  specimen 
from  females  the  vagina  is  douched  and  the  external 
genitalia  completely  cleansed.  Catheterization  in  females 
should  only  be  resorted  to  in  case  the  examination  of  the 
first  specimen  is  made  difficult  by  epithelium  and  pus-cells 
from  the  vagina.  The  specimen  should  be  sent  to  the 
pathologist  for  immediate  examination.  In  addition,  the 
total  quantity  passed  in  the  first  twenty-four  hours  of  the 
patient's  stay  in  the  hospital  is  to  be  saved  and  a  sample 
of  the  mixed  urine  sent  for  analysis.  In  the  event  of  the 
discovery  of  any  pathologic  condition  of  the  kidneys, 
bladder,  or  urethra,  suitable  treatment  is  at  once  inaugu- 
rated and  subsequent  urinalyses  made  sufficiently  often 
to  note  the  progress  of  the  condition.  The  urinalysis 
reports  form  an  important  part  of  the  history  of  the 
case. 

The  Skin. — ^A  hot  water  and  soap  tub  bath  is  given 
immediately  following  admission  and  before  the  patient 
is  put  to  bed.  The  entire  surface  of  the  body  is  vigor- 
ously scrubbed  with  soap-suds  and  a  soft  brush.  Par- 
ticular attention  is  paid  to  the  head,  axillae,  genitals,  anal 
region,  hands,  and  feet;  the  finger-nails  and  toe-nails 
should  be  cut  short,  and  the  subungual  spaces  well 
scrubbed.  The  bath  is  repeated  daily  until  the  day  of 
operation,   when   a   sponge   bath   is   substituted   for   it. 


78  OPERATING    ROOM    AND    THE    PATIENT. 

Patients  too  weak  to  be  given  tub  baths  receive  sponge 
baths  instead. 

The  Bowels. — Those  cases  which  permit  of  it,  forty- 
eight  hours  before  the  operation,  should  be  given  one -half 
ounce  of  magnesia  sulphate  in  cool  water.  The  dose  may 
be  made  more  palatable  by  substituting  equal  parts  of 
orange-juice  and  lemon-juice  for  the  water,  and  adding 
only  enough  of  this  to  liquefy  the  magnesia,  then  adding  a 
small  quantity  of  cracked  ice.  This  is  repeated  every  six 
hours  until  the  bowels  move  thoroughly.  The  evening 
before  the  operation,  the  lower  bowel  is  washed  out  with 
a  liberal  soapsuds  enema.  This  is  repeated  four  to  six 
hours  before  the  operation.  In  cases  allowing  of  but 
twenty-four  hours'  preparation,  the  same  plan  is  followed, 
except  the  interval  between  the  doses  of  magnesia  is 
shortened  to  two  hours.  In  emergency  cases  the  mag- 
nesia is  omitted,  and  a  large  soapsuds  enema  given 
immediately  following  the  sponge  bath. 

The  Diet. — ^The  diet  should  be  highly  nutritious, 
rapidly  assimilable,  and  such  as  to  leave  the  minimum 
residue  in  the  intestines.  The  patient  should  be  en- 
couraged to  indulge  in  liberal  quantities  of  fluid  up  to 
within  six  hours  of  the  time  set  for  operating.  In  these 
six  hours  nothing  should  be  introduced  into  the  stomach. 
The  meal  directly  preceding  the  operation  should  be 
omitted  as  far  as  solid  articles  of  food  are  concerned. 
There  is  no  objection,  however,  to  the  ingestion  of  water, 
tea,  or  thin  soup  so  long  as  six  hours  elapse  between  the 
time  these  are  taken  and  the  operation.  In  emergency 
cases  which  have  recently  partaken  of  a  meal  the. 
stomach  should  be  washed  out.  Debilitated  patients 
should  receive  rectal  alimentation  every  six  hours  in 
addition  to  being  fed  by  stomach. 

Local  Preparation. — -General  Directions. — Twenty-four 
hours  preceding  the  time  set  for  operating  the  skin  of  the 
field    of    operation   should   be    shaved   and   thoroughly 


THE    PATIENT.  79 

cleansed  with  hot  water,  green  soap,  and  a  gauze  com- 
press. The  surface  should  then  be  carefully  wiped  off 
with  alcohol  and  the  entire  area  covered  with  towels 
wrung  out  of  boro-salicylic  solution.  These  in  turn  are 
covered  with  oiled  muslin  protective  and  secured  by 
bandage  or  binder.  Twelve  hours  later  the  surface  is 
again  cleansed  with  hot  water  and  green  soap  and  the 
loose  epithelium  removed  by  sponging  with  alcohol. 
The  surface  is  then  covered  with  towels  wrung  out  of 
I  :  5000  bichlorid  and  then  by  a  layer  of  non-absorbent 
cotton,  the  whole  being  secured  by  bandage  or  binder. 
In  emergency  cases  following  the  cleansing  with  green 
soap  and  hot  water  the  bichlorid  towels  are  applied,  the 
cotton  being  omitted.  While  the  local  preparation  of  the 
parts  should  be  thorough,  it  is  well  to  remember  that  an 
overzealous  and  too  vigorous  preparation  will  tend  to 
defeat  the  end  aimed  at  by  abrading  the  skin  and  thus 
opening  up  avenues  of  infection. 

The  Head. — The  hair  of  the  entire  head,  except  in  the 
case  of  small  tumors  or  wounds,  is  first  cut  short  with 
scissors  and  then  shaved.  In  any  event,  the  hair  must 
be  removed  wide  of  the  site  of  operation.  The  remaining 
hair  is  cleansed  by  shampooing  with  soap  and  hot  water ; 
thoroughly  rinsed  in  cold  water;  then  rubbed  with 
alcohol  and  bichlorid,  i  :  5000 ;  finally  thoroughly  dried, 
braided  in  the  case  of  females,  and  covered  with  a  cap  or 
bandage.  The  eyebrows  should  not  be  shaved,  but 
should  be  completely  disinfected.  In  operations  near  or 
involving  the  mouth  or  nose,  the  beard  and  mustache 
should  be  removed.  The  ears  should  be  cleansed  and 
lightly  packed  with  sterile  cotton. 

The  Mouth. — Preceding  all  operations  upon  the  mouth 
the  condition  of  the  teeth  should  be  investigated  and 
made  as  perfect  as  possible  before  the  patient  enters  the 
hospital.  The  teeth  should  be  cleansed  with  a  brush 
after   each   meal,    and   in   addition   an   astringent   and 


8o  OPERATING    ROOM    AND    THE    PATIENT. 

antiseptic  mouth-wash  and  nasal  douche  should  be 
employed  every  three  hours.  Ulcerative  conditions  such 
as  are  present  in  carcinoma  of  the  tongue  should  be 
treated  by  lightly  touching  them  with  5  per  cent,  zinc 
chlorid  solution  or  10  per  cent,  chromic  acid  solution. 
Weak  solutions  of  permanganate  of  potassium  make 
good  washes  in  this  condition. 

The  Neck. — In  operations  in  this  region  the  hair  on  the 
side  to  be  operated  upon  is  shaved  to  above  the  level  of  the 
ear.  The  rest  of  the  hair  is  shampooed  as  for  operations 
upon  the  head.  The  ears  are  cleansed  and  packed  with 
sterile  cotton.  The  axillae  should  be  carefully  disin- 
fected, as  it  is  here  that  the  bacillus  pyocyaneus  has  its 
habitat.  It  is  not,  however,  necessary  to  shave  the  axil- 
lag.  The  shoulder  and  chest  should  be  included  in  the 
preparation. 

The  Thorax. — Both  axillae  should  be  disinfected;  the 
one  upon  the  side  to  be  operated  upon  should  be  shaved. 
The  arm  upon  this  side  should  be  included  in  the  prepara- 
tion, as  well  as  the  shoulder  and  upper  part  of  the  ab- 
domen. 

The  Abdomen. — The  disinfection  should  include  all  the 
skin  from  the  line  of  the  nipple  to  the  middle  third  of  the 
thigh  and  as  far  back  as  the  postaxillary  line ;  also  the 
perineum,  genitalia,  and  inside  of  the  thighs. 

The  Genitals. — The  preparation  should  include  the 
lower  abdomen  and  upper  third  of  the  thigh,  as  well  as 
the  external  genitalia  and  perineum.  In  males  the 
prepuce  should  be  carefully  cleaned  and  in  females  the 
clitoris.  In  operations  involving  the  vagina,  as  well  as  in 
laparotomy  cases,  the  mucous  membrane  is  cleaned  by 
douching  twice  or  thrice  daily  with  hot  boro-salicylic 
solution.  In  septic  conditions  the  boro-salicylic  douche 
is  preceded  by  a  i  :  2000  bichlorid  douche. 

The  Rectum  and  Anus. — The  preparation  includes  the 
perineum,   buttocks,   genitalia,   and  upper  third  of  the 


THE   PATIENT.  8 1 

thigh.  Copious  soapsuds  enemata  should  be  given  to 
cleanse  the  rectum,  but  sufficient  time  should  elapse 
between  the  last  enema  and  the  time  set  for  the  operation 
(six  hours)  to  allow  the  enema  entirely  to  come  away; 
otherwise  it  may  be  expelled  during  the  course  of  the 
operation. 

The  Extremities. — In  operations  upon  the  arm  the 
axilla  and  shoulder  should  be  included  in  the  prepara- 
tion ;  in  the  case  of  the  thigh  the  genitalia  and  hip  should 
be  included.  In  operations  upon  joints  the  entire 
extremity  should  be  prepared.  The  preparation  of  the 
hands  and  feet  is  part  of  the  general  preparation  of  the 
patient.  Areas  such  as  the  elbow,  knee,  and  sole  of  the 
foot  should  receive  more  careful  attention  than  areas 
where  the  skin  is  not  so  thick.  In  these  areas  the  boro- 
salicylic  compresses  should  be  renewed  every  four  hours 
and  the  loosened  epithelium  removed  by  sponging  with 
alcohol. 

The  Nose  and  Pharynx. — In  addition  to  nasal  douching 
and  sponging  minute  doses  of  atropin  and  morphin  will 
be  found  valuable  in  limiting  excessive  secretion. 

The  Esophagus  and  Stomach. — The  stomach  should  be 
washed  out  shortly  before  the  operation.  The  washing 
should  continue  until  the  fluid  returns  clear,  when  the 
remainder  should  be  siphoned  out,  leaving  the  stomach 
empty. 

The  Small  and  Large  Intestines. — The  most  we  can  hope 
to  accomplish  is  a  diminution  in  the  number  of  bacteria 
which  here  normally  find  their  habitat.  This  is  accom- 
plished by  thorough  purgation  and  the  ingestion  of  food 
leaving  the  smallest  residue. 

The  Urinary  System. — By  increasing  the  amount  of 
fluids  taken  by  the  patient  and  by  repeated  doses  of  such 
drugs  as  urotropin  and  caffein  citrate  we  can  increase  the 
functional  activity  of  the  kidneys  and  so  flush  out  the 
urinary  tract.     In  operations  involving  the  bladder  and 


82 


OPERATING    ROOM    AND    THE    PATIENT. 


in  which  a  septic  condition  of  the  urine  exists,  we  can, 
when  time  permits,  catheterize  every  six  or  eight  hours 


and  wash  out  the  bladder  with  boro-salicylic  solution, 
following  this  with  boric  acid  solution.     An  ounce  or  two 


THE    PATIENT. 


83 


of  the  latter  may  be  left  in  the  bladder.     In  operations 
involving  the  urethra,  should  septic  conditions  be  present, 


Fig.    14. — Dependent  head  position. 


Fig.    15. — Extended  neck  position. 


thorough  irrigation  through  a  small  catheter  with  boro- 
salicylic  solution  should  be  practised. 

Preparation  Just  Previous  to  Anesthetization. — A  freshly 
laundered,  light  flannel  night  shirt  open  in  the  back,  is  put 


84  OPERATING   ROOM   AND   THE   PATIENT. 

on  the  patient ;  also  a  cap  or  bandage  to  confine  and  pro- 
tect the  hair,  and  long  stockings.  These  latter  should 
come  well  up  on  the  thighs.  The  patient  should  be  asked 
to  urinate.  If  this  is  impossible  or  if  the  quantity  passed 
is  small  in  amount  catheterization  is  employed  if  the 
patient  be  a  female  and  the  operation  involves  the  pelvic 
viscera;  otherwise  catheterization  may  be  omitted.  In 
any  case  the  fact  should  be  recorded,  and  those  cases 
which  do  not  urinate  voluntarily  or  which  are  not  cathe- 


Fig.  1 6. — Position  for  breast  amputation. 


terized  should  be  subsequently  watched  for  distention  of 
the  bladder.  As  a  rule,  strychnin  sulphate,  gr.  j^  to 
-jVj  is  administered  hypodermatically  just  previous  to 
anesthetization. 

The  position  of  the  patient  on  the  operating  table  will 
vary  according  to  the  nature  of  the  operation.  It  should 
be  such  as  will  render  the  part  involved  in  the  operation 
prominent  and  ready  of  access  and  yet  such  as  to  interfere 
as  little  as  possible  with  respiration  and  circulation,  and 


THE    PATIENT. 


85 


there  should  be  no  pressure  on  important  nerves.  In 
short,  the  position  should  be  as  natural  as  possible.  The 
musculospiral  nerve  is  the  nerve  most  frequently  injured. 
This  occurs  through  allowing  the  arm  to  rest  against  the 
edge  of  the  table.  It  may  be  caused  by  an  assistant 
leaning  against  the  arm. 

The  dependent  head  position  is  used  in  operations  upon 
the  mouth  and  nose.     Its  object  is  to  prevent  the  entrance 


Fig.  17. — Thoracotomy  position. 


of  blood  into  the  larynx.  The  patient  lies  in  the  dorsal 
position,  arms  by  the  side,  with  the  head  hanging  over  the 
end  of  the  table.  The  back  of  the  neck  is  protected  by 
placing  under  it  a  small,  fiat  pad.  The  vertex  of  the  head 
may  be  supported  by  the  hand  of  an  assistant. 

The  extended  neck  position  is  produced  by  placing  the 
patient  in  the  dorsal  position,  arms  by  the  side,  with  a 
large,  flat  sand-bag  beneath  the  shoulders.  The  sand- 
bag should  be  of  such  thickness  as  will  allow  the  head  to 


86 


OPERATING    ROOM    AND    THE    PATIENT. 


rest  on  the  table  without  excessive  extension  of  the  neck. 
This  position  is  used  in  operations  upon  the  anterior  and 
lateral  regions  of  the  neck. 

The  position  for  amputation  of  the  breast  is  the  dorsal 
position  with  a  fiat  sand-bag  under  the  thorax  on  the 
affected  side.  The  patient  lies  near  the  edge  of  the  table 
on  that  side.  The  arm  of  the  affected  side  is  flexed  at  the 
elbow,  abducted  to  a  right  angle  at  the  shoulder,  and  held 
in  that  position  by  bandaging  the  wrist  loosely  to  the 
table .     The  other  hand  lies  close  to  the  patient '  s  side .    The 


Fig.   1 8. — Position  for  operations  upon  the  upper  abdomen. 


patient's  face  is  turned  away  from  the  affected  side  so  that 
the  administration  of  the  anesthetic  will  not  interfere  with 
the  operator.  Before  the  introduction  of  the  sutures  the 
arm  is  brought  to  the  side. 

The  position  for  thoracotomy  is  similar  to  the  above 
except  that  a  larger  sand-bag  is  used  and  the  lateral  chest 
wall  more  exposed  by  allowing  the  arm  of  the  affected 
side  to  lie  across  the  chest.  The  affected  side  should  be 
well  over  the  side  of  the  table. 

The  position  for  operations  upon  the  upper  abdomen  is  the 


THE    PATIENT. 


87 


dorsal  position  with  a  moderately  large  sand-bag  under  the 
dorsal  spine.     The  arms  should  be  placed  above  the  head. 


Q 


fe 


The  dorsal  position  is  with  the  patient  flat  on  the  back. 
The  arms  may  be  either  folded  across  the  chest,  fastened 


88  OPERATING    ROOM    AND    THE    PATIENT. 

naturally  above  the  head,  or  allowed  to  rest  at  the  side. 
This  position  is  the  one  usually  employed. 

The  Trendelenburg  position  is  secured  by  placing  the 
patient  in  the  dorsal  position,  with  the  shoulders  resting 
against  shoulder  supports.  The  head  of  the  table  is  then 
depressed  as  soon  as  required.  For  operations  upon  the 
small  intestine  or  appendix,  a  moderate  degree  of  Tren- 
delenburg position  is   useful.     In   demonstrating  intra - 


Fig.  20. — Trendelenburg  position. 


pelvic  Operations  an  exaggerated  Trendelenburg  position 
is  necessary.  The  weight  of  the  body  should  rest  on  the 
shoulder.  To  prevent  pressure  effects,  rubber  pads 
should  be  placed  between  the  skin  and  the  supports.  The 
arms  should  be  fastened  loosely  across  the  chest. 

The  reversed  Trendelenburg  position  is  useful  in  opera- 
tions for  varicocele  and  varicositis  of  the  lower  extremity 
and  in  limiting  infection  to  the  lower  abdomen.  The 
patient  is  secured  to  the  table  by  bandages  and  ad- 


THE  PATIENT.  89 

hesive  plaster  strips   so  arranged  as  to  distribute  the 
weight. 

The  lithotomy  position  is  obtained  by  placing  the 
patient  in  the  dorsal  position  and  flexing  the  thighs  on 
the  abdomen  with  the  legs  flexed  at  a  right  angle.  The 
patient  should  then  be  drawn  down  on  the  table  until  the 
buttocks  project  well  over  the  edge.     The  position  may 


Fig.  21. — Reversed  Trendelenburg  position. 

be  maintained  by  a  sling  sheet.  To  do  this,  a  large  sheet 
is  folded  diagonally  and  placed  with  the  apex  hanging 
slightly  over  the  foot  of  the  table.  The  patient  is  then 
placed  on  the  table  in  the  lithotomy  position,  with  the 
buttocks  resting  upon  the  apex  of  the  sheet  and  the 
shoulder  upon  the  upper  folded  portion.  Each  lateral 
corner  of  the  sheet  is  then  passed  around  the  thigh  from 
the  outside  and  drawn  taut.     One  end  is  then  passed 


go 


OPERATING    ROOM    AND    THE    PATIENT. 


back  of  the  neck  and  secured  by  knotting  to  the  other  end. 
A  more  secure  position  is  obtained  by  using  the  foot- 
holders  and  Hthotomy  posts.  Care  should  be  taken  not 
to  overflex  the  thighs  nor  to  allow  the  inside  of  the  legs 
to  be  pressed  tightly  against  the  posts. 


Fig.    2  2. — Lithotomy  position,  with  sUng  sheet. 


The  exaggerated  lithotomy  position  is  similar  to  the 
above  except  that  the  pelvis  is  elevated  either  by  placing 
a  large  flat  sand -bag  beneath  the  buttocks  or  by  combin- 
ing with  the  Trendelenburg  position.  In  the  latter 
event,  the  shoulder  supports  should  be  so  placed  as  to 
prevent  the  patient  slipping  away  from  the  edge  of  the 


THE    PATIENT. 


91 


table.  This  position  is  useful  in  clean  vaginal  sections  to 
aid  in  keeping  the  intestines  out  of  the  pelvis,  and  in 
rectal  operations. 

The  Sims'  position  is  obtained  by  placing  the  patient 
upon  the  left  side,  the  left  side  of  the  face,  left  shoulder, 
and  breast  resting  upon  a  very  fiat  pillow.  The  left  arm 
lies  straight  on  the  table  behind  the  patient ;  the  right 
arm,  bent  at  the  elbow,  lies  naturally  across  the  chest. 


Fig.    23. — Lithotomy  position. 


The  buttocks  lie  near  the  edge  of  the  table ;  the  knees  are 
flexed  and  drawn  up  toward  the  abdomen,  the  right  knee 
nearer  the  abdomen  than  the  left. 

The  kidney  position  is  secured  by  first  placing  the 
patient  in  Sims'  position,  either  upon  the  right  or  left 
side,  as  required ;  then  introducing  an  oblong  sand  pillow 
between  the  table  and  the  flank  so  as  to  cause  the  kidney 
region  on  the  affected  side  to  become  prominent.     The 


92  OPERATING    ROOM    AND    THE    PATIENT. 

sand-bag  should  be  sufficiently  large  to  cause  a  flattening 
of  the  affected  side  by  widening  the  space  between  the 
ribs  and  the  iliac  crest.  The  patient  should  lie  more  upon 
the  side  than  in  Sims'  position.  This  is  maintained  by 
a  second  large  sand-bag  placed  parallel  to  the  abdomen 
or  by  securing  the  patient  to  the  table  by  a  broad,  ad- 


Fig.  24. — Exaggerated  lithotomy  position. 

hesive  plaster  strip  crossing  the  body  at  the  level  of  the 
ensiform.  The  ventral  position  is  flat  on  the  belly  with 
the  head  turned  to  one  side.  In  operating  upon  both 
kidneys,  as  in  removal  of  the  capsule  or  double  suspension 
operations,  this  position  is  exaggerated  by  placing  a  large 
sand-bag  under  the  abdomen.  The  arms  lie  above  the 
head. 


THE    PATIENT. 


93 


The  knee-chest  position  is  useful  in  direct  examinations 
of  the  rectum  and  the  bladder.  The  patient  kneels  upon 
the  table  and  with  the  thighs  at  right  angles  to  the  legs 


Fig.  25.— Sims'  position. 


Fig.  26. — Single  kidney  position. 


inclines  the  body  until  the  chest  rests  upon  a  rather  large 
pillow,  the  head  being  turned  to  one  side;  the  arms, 
flexed  at  the  elbow,  help  to  support  the  body. 


94 


OPERATING    ROOM    AND    THE    PATIENT, 


Final  Preparation  of    the   Field    of    Operation. — The 

assistant  house  surgeon  should  have  thoroughly  disin- 


Fig.    27. — Ventral  position. 


Fig.    28. — Knee-chest  position. 


fected  his  hands  before  anesthesia  is  established.     He 
should  have  on  cap,  mask,  and  rubber  apron,  but  should 


THE    PATIENT. 


95 


not  don  his  gown  until  he  has  finished  preparing  the 
patient  and  has  again  disinfected  his  hands.     In  handling 


the  patient  he  should  make  use  of  bichlorid  towels.     The 
anesthetic  being  established,  the  patient  is  wheeled  to 


96  OPERATING    ROOM    AND    THE    PATIENT. 

the  operating  table  on  which  are  rubber  pads  and  a  rubber 
sheet,  and  lifted  from  the  cart  to  the  table  by  means  of 
the  small  stretcher,  the  anesthetist  supporting  the  head 
and  shoulders,  while  the  body  is  supported  by  the  orderly 
lifting  on  the  cart  side  of  the  stretcher,  and  the  assistant 
house  surgeon  lifting  from  across  the  table.  The  stretcher 
is  then  removed  and  the  patient  placed  in  the  required 
position.  The  half  blankets  are  arranged  smoothly  so  as 
widely  to  expose  the  field  of  operation,  the  bichlorid 
towels  and  bandages  removed,  and  the  area  to  be  disin- 
fected surrounded  with  sterile  towels.  The  parts  are  then 
carefully  scrubbed  for  three  minutes,  in  emergency  cases 
five  minutes,  with  green  soap,  hot  water,  and  a  sterile 
gauze  compress.  The  soapsuds  are  washed  away  with 
sterile  water.  The  skin  is  then  gone  over  carefully  with 
alcohol  and  ether,  and  finally  flushed  with  bichlorid, 
I  :  2000,  a  fresh  compress  being  used  for  each  solution. 
In  place  of  this  elaborate  preparation,  if  the  ward  prepara- 
tion has  been  thorough,  it  is  only  necessary  to  sponge  the 
part  with  the  acid-bichlorid  solution  for  two  minutes. 
The  line  of  incision  is  painted  with  iodin  on  a  stick  sponge. 
Sufficient  bichlorid  should  have  been  added  to  the  iodin 
to  make  a  i  :  1000  solution.  In  emergency  cases  prepared 
on  the  table  the  same  procedure  should  be  carried  out 
as  in  ward  preparations  except  that  the  disinfection 
should  be  of  longer  duration.  In  ulcerative  conditions 
of  the  skin,  the  area,  after  scrubbing,  is  painted  with 
tincture  of  iodin.  Sinuses  are  disinfected  by  curetting 
and  packed  with  sterile  gauze.  The  nipple  in  breast 
operations  and  the  umbilicus  in  abdominal  operations 
is  coated  with  Woelfler's  solution  to  which  sufficient 
bichlorid  has  been  added  to  make  a  strength  of  i  :  1000. 
In  abdominal  operations  in  the  female  no  more  than  the 
ward  preparation  of  the  vagina  is  necessary,  unless  a 
preliminary  curettage  is  to  be  done.  In  septic  endome- 
tritis cases  a  bichlorid  douche  is  added  to  the  repetition 


THE    PATIENT. 


97 


of  the  usual  disinfection.     In  operations  upon  the  bladder, 
if  septic  conditions  be  present,   the  bladder  should  be 


03 


irrigated    with    borosalicylic    solution.     In    operations 
upon  the  rectum  and  anus  the  sphincter  should  be  mas- 

7 


98  OPERATING    ROOM    AND    THE    PATIENT. 

saged  and  gradually  dilated,  a  speculum  inserted,  and  the 
rectum  washed  out  with  a  boro-salicylic  solution.  Dur- 
ing dilatation  of  the  sphincter  the  anesthetic  should  be 
discontinued,  otherwise  a  dangerous  depth  of  narcosis 
might  result.  Having  completed  the  local  disinfection, 
the  assistant  house  surgeon  lifts  the  patient  while  the 
nurse  removes  the  rubber  drainage  sheet.  He  then  pro- 
ceeds to  redisinfect  his  hands,  and  dons  a  gown  prepar- 
atory to  assisting  at  the  operation.  The  house  surgeon 
assists  the  operating  room  nurse  in  arranging  the  pro- 
tectors and  towels.  Every  part  of  the  patient  except 
the  immediate  field  of  operation  should  be  covered.  No 
bichlorid  towels  should  be  used  except  in  operating  upon 
the  extremities.  The  patient  should  be  kept  as  dry  as 
possible.  The  towels  and  protectors  are  held  in  place  by 
sterile  safety  pins. 

Hand  Disinfection. — Skin  disinfection  has  for  its  object 
the  mechanic  removal  of  germs  from  the  surface  of  the 
skin,  the  chemic  inhibition  of  germs  which  are  brought 
from  the  depths  of  the  skin  to  the  surface  by  the  sweat 
and  sebaceous  glands,  and  the  mechanic  lessening  of  the 
conditions  which  produce  sweating.  There  is  at  present 
no  method  by  which  these  aims  can  be  certainly  attained. 
A  hand  which  is  scrubbed  clean  mechanically  and  which 
gives  no  culture  will,  upon  being  moved  about  for  a  few 
minutes,  give  a  culture.  With  the  object  of  overcoming 
the  conditions  present  so  far  as  possible,  the  following 
procedure  is  advocated : 

The  hands  and  forearms  are  first  vigorously  scrubbed 
for  five  minutes  with  green  soap  and  a  soft  brush  in  hot, 
running  water.  The  hot  water  causes  sweating,  thus 
bringing  to  the  surface  at  least  some  of  the  bacteria 
residing  in  the  depth  of  the  skin.  The  vigorous  scrubbing 
facilitates  this  and  removes  the  bacteria  on  the  surface. 
A  good  lather  should  be  raised  which  is  rinsed  off  in  hot 
water.     The  nails  softened  by  the  hot  water  are  then 


THE    PATIENT.  99 

trimmed  down  to  the  quick,  not  close  enough  to  be  pain- 
ful, but  close  enough  to  obliterate  the  subungual  spaces. 
The  only  way  to  disinfect  the  subungual  spaces  is  to  destroy 
them.  For  those  who  object  to  trimming  their  nails  so 
short,  a  wire  nail  cleaner  is  recommended.  The  hands 
and  forearm  are  again  scrubbed  with  green  soap  and  a 
second  brush  in  hot  water  for  another  five  minutes.  The 
brush  must  not  be  so  stiff  or  used  so  vigorously  as  to 
abrade  the  skin;  so  doing  would  open  up  avenues  of 
infection  quite  needlessly.  The  lather  is  rinsed  off 
frequently.  After  a  final  rinsing,  the  hands  are  immersed 
for  one  minute  in  a  i  :  2000  bichlorid  of  mercury  solution, 
then  for  one  minute  or  until  deeply  stained  in  a  hot 
bichlorid-permanganate  solution.  This  latter  serves 
three  purposes:  the  permanganate  penetrates  the  skin 
deeply,  and  so  carries  the  bichlorid  into  the  depth  of  the 
skin ;  owing  to  its  astringency,  it  contracts  the  tissue  and 
so  tends  to  prevent  sweating;  in  addition,  it  forms  a 
film  on  the  surface  of  the  skin  and  so  tends  to  prevent 
the  entrance  of  infection  as  well  as  the  egress  of  bacteria 
from  the  depth  of  the  skin.  Finally,  during  the  operation 
at  intervals  of  five  minutes  the  hands  should  be  rinsed  in 
cold  bichlorid  solution  i  :  3000  or  i  :  4000  in  50  per  cent 
alcohol.  This  serves  to  rinse  off  such  bacteria  as  lodge 
on  the  surface  or  work  out  from  the  depths  of  the  skin, 
and  the  low  temperature  of  the  solution  and  the  alcohol 
present  tend  to  minimize  sweating.  In  case  of  skin- 
grafting  saline  solution  is  used  for  the  hands  in  place  of 
bichlorid  solution. 

The  after-care  of  the  hands  is  important.  The  hands 
are  gently  scrubbed  in  hot  water  to  open  up  the  pores,  all 
soap  rinsed  off,  and  then  immersed  in  a  saturated  hot 
solution  of  oxalic  acid.  This  removes  the  permanganate. 
The  hands  are  rinsed  in  warm  water  and  then  in  cold 
ammonia  solution,  one  ounce  of  ammonia  to  two  quarts 
of  water.     This  neutralizes  the  effect  of  the  oxalic  acid, 


lOO 


OPERATING    ROOM    AND    THE    PATIENT. 


and  when  a  little  liquid  green  soap  is  added  it  results  in 
thoroughly  cleaning  the  hands,  leaving  them  white  and 
soft.  If  the  hands  feel  dry,  lanolin  may  be  rubbed  into 
the  skin. 


Fig.   31. — Dorsal  position;  abdominal  dressing  applied. 


Fig.   32. — Dorsal  position;  abdominal  binder  applied. 


Before  disinfecting  the  hands  and  forearm  a  cap,  mask, 
and  rubber  apron  should  be  donned.  After  disinfection  is 
completed  a  sterile  gown  is  put  on. 

The  application  of  dressings  is  usually  done  by  the  house 
surgeon  under  the  direction  of  the  adjunct.     Prior  to 


THE    PATIENT.  lOI 

applying  the  usual  dressing,  the  skin  in  the  neighborhood 
is  cleaned  with  hydrogen  peroxid,  flushed  with  saline 
solution,  and  thoroughly  dried.  The  wound  dressing  is 
then  applied.  The  parts  which  will  be  covered  with  the 
outer  dressing  and  bandage  or  binder  are  next  dried  and 
the  dressing  completed.  In  securing  bandages  with  pins 
care  should  be  taken  not  to  wound  the  skin.  In  moving 
the  patient  about  care  should  be  taken  to  place  no  addi- 
tional strain  upon  the  sutures.  The  purpose  of  the  dress- 
ing is  to  relieve  strain  and  insure  rest  of  the  parts  as  well 
as  to  protect  the  wound  against  infection.  Dead  spaces 
should  be  obliterated.  The  back-rest  or  an  inverted 
basin  is  used  to  facilitate  the  application  of  dressings  to 
the  trunk.  All  dressings  should  fit  smoothly  and  be  a 
source  of  comfort  to  the  patient.  Dressings  on  the 
cervical  region  should  include  the  head,  shoulder,  and 
thorax.  Thorax  dressings  should  include  the  shoulder 
and  upper  abdomen.  Adbominal  dressings  should  go  well 
over  the  flanks,  thighs,  and  lower  portion  of  the  thorax. 
In  applying  the  abdominal  binder  the  binder  should  be 
rolled  up  halfway  lengthwise;  the  patient  should  be 
rolled  partly  on  the  side  and  the  rolled  portion  of  the 
binder  placed  beneath;  by  rolling  the  patient  partially 
in  the  other  direction  the  rolled-up  portion  of  the  binder 
can  be  grasped  and  unrolled.  The  binder  is  pulled  taut. 
It  should  extend  well  down  on  the  thighs  and  well  up  on 
the  lower  part  of  the  thorax,  and  should  fit  snugly.  The 
ends  are  folded  on  themselves  and  pinned,  the  one  over 
the  other  in  the  middle  line.  A  vertical  line  of  safety  pins 
over  each  flank  causes  the  binder  to  fit  more  closely  to  the 
body.  Two  perineal  straps  which  follow  the  gluteal  fold 
keep  the  binder  in  position.  Vulva  and  perineal  dressings 
are  retained  in  position  by  T-bandages.  In  applying 
splints,  such  as  the  Volkmann,  to  the  lower  extremities 
the  foot  should  be  first  attached  in  the  desired  position 
to  the  splint  before  bandaging  the  rest  of  the  extremity. 


CHAPTER  VI. 

GENERAL  CONSIDERATIONS  IN  THE  AFTER 
TREATMENT. 

General  considerations.  Purpose.  The  bed.  Position  of  patient. 
Pressure  of  bedclothes.  Bed-rest.  Frame  for  elevated  head  and 
trunk  posture.  Stay  in  bed.  Recovery  from  anesthesia.  Anesthetic 
vomiting.  Persistent  vomiting.  General  appearance  of  the  patient. 
Parotitis.  Pain.  Thirst.  Nutrition.  Appetite.  Diet.  Digestion. 
Distention.  Intestinal  toxemia.  Fecal  impaction.  General  hygiene. 
Bath.  Massage.  Urine.  Albuminuria.  Diabetes.  Urinalysis. 
Cystitis.  Anuria.  Retention  of  urine.  Catheterism  in  the  female. 
Vesical  irritability.  Danger  of  infection.  Temperature.  Intestinal 
fermentation.  Autointoxication.  Aseptic  fever.  Normal  wound 
temperature.       Pneumonia.  Bronchitis.       Nephritis.      Superficial 

wound  infection.  Deep  infection.  Stitch  abscesses.  Fever  due  to 
other  causes.     Pulse.     Respiration. 

General  Consideration. — A  successful  issue  in  many 
cases  depends  upon  the  care  which  is  exercised  in  the 
after-treatment.  The  surgeon's  responsibility  does  not 
end  with  the  laying  down  of  the  scalpel,  but  continues 
until  healing  is  complete.  Many  operative  procedures 
would  be  absolutely  negatived  by  failure  to  carry  out  the 
proper  after-treatment.  It  would  be  of  slight  avail  to 
cut  urethral  stricture  if  the  passage  of  sounds  were  not 
rigidly  enforced;  nor  would  a  good  result  be  obtained 
following  resections  of  bones  and  joints  if  no  attention 
were  paid  to  the  position  of  the  parts.  The  occurrence  of 
pressure  sores  in  patients  who  have  long  been  confined 
to  bed,  has  caused  many  surgeons  to  regret  that  they  did 
not  pay  more  attention  to  the  details  of  their  work. 

The  purpose  of  the  after-treatment  is  to  recognize  com- 
plications early,  be  they  simple  or  grave,  and  so  intelli- 
gently to  treat  them  as  to  give  the  patient  not  only  the 


THE    AFTER    TREATMENT. 


103 


best  chance  for  recovery,  but  the  best  final  functional 
result.  Not  only  must  the  wound  or  injury  itself  be 
treated,  but  the  entire  organism  must  be  brought  to  as 
nearly  a  normal  condition  as  possible.  Each  case  must 
be  studied  individually  as  regards  previous  habits  of  life 
and  complicating  diseases.  The  mental  status  of  the 
patient  must  be  understood.  The  general  physical 
condition  must  receive  attention.     The  working  of  every 


^ 


Fig.   33. — Bed  ready  to  receive  patient. 


organ  must  be  known  in  order  to  treat  the  case  intelli- 
gently. 

The  bed  should  be  easily  separable  for  purposes  of 
cleanliness.  Enameled  iron  bedsteads  with  wire  springs 
serve  admirably.  They  have  the  advantage  of  being 
cheap,  and  are  practically  indestructible. 

Preparation  of  the  bed  for  reception  of  the  patient: 
Either  a  thin  hair  mattress  is  placed  on  the  wire  spring  or 
a  heavy  folded  blanket  is  used  for  the  purpose.  The 
bedclothes  consists  of  two  sheets,  an  upper  and  an  under 


I04  OPERATING    ROOM    AND    THE    PATIENT. 

one,  and  a  draw-sheet  of  thin  rubber,  two  light  blankets, 
a  counterpane,  and  a  small,  fiat  pillow.  Hot-water 
bottles  are  placed  between  the  blankets  half  an  hour 
before  the  return  of  the  patient  to  bed  is  expected. 

The  position  of  the  patient  will  depend  upon  the  char- 
acter of  the  operation.  The  position  should  be  as  com- 
fortable as  is  compatible  with  proper  rest  of  the  operated 
part.  Unnecessary  movements  are  to  be  avoided. 
During  the  first  few  hours  shock  may  necessitate  the 
elevated  pelvis  posture.  Subsequently  the  patient  may 
be  placed  on  one  side,  as  in  empyema  or  renal  operation; 
or  the  elevated  head  and  trunk  position  may  be  em- 
ployed if  diffuse  peritonitis,  excessive  vomiting,  or  other 
indication  for  its  use  occur.  In  uncomplicated  cases  a 
small  pillow  beneath  the  head  will  be  a  source  of  comfort. 
Following  herniotomy  or  other  abdominal  section  a 
pillow  under  the  knees  will  make  the  patient  more 
comfortable  by  relieving  the  tension  on  the  abdominal 
wall.  Sand-bags  will  be  necessary  to  maintain  quiet  of 
an  injured  member.  Should  extension  of  a  limb  be 
necessary,  a  board  must  be  placed  beneath  the  mattress 
to  give  the  required  stability.  Pressure  from  the  bed- 
clothes is  avoided  by  hoops  or  frames  which  keep  the 
weight  of  the  bedclothes  from  the  body.  Barrel-hoops 
form  a  good  substitute  for  the  manufactured  frames. 
Rubber  rings  and  pillows  are  useful  in  maintaining  the 
patient  in  a  comfortable  position.  The  water-bed  may 
be  necessary  in  spinal  cases  or  in  much  debilitated  cases. 
In  cases  in  which  hemorrhage  or  oozing  is  feared,  the  parts 
affected  may  be  elevated  to  lessen  the  flow  of  blood  to 
them  and  hasten  the  flow  from  them;  in  other  words, 
congestion  of  the  parts  is  to  be  avoided.  Old  and 
debilitated  patients  should  have  the  shoulders  propped 
up  and  their  position  changed  frequently  in  order  to  avoid 
hypostatic  pneumonia. 

The  bed-rest  will  be  found  useful  as  convalescence  pro- 


THE    AFTER    TREATMENT.  105 

ceeds.  The  stay  in  bed  should  be  as  short  as  is  com- 
patible with  wound  healing.  As  soon  as  possible,  the 
patient  should  be  taken  into  the  open  air  and  sunshine. 

Recovery  from  Anesthesia. — The  patient  is  to  be 
watched  until  conscious.  Under  no  circumstances  is  he 
to  be  left  alone  until  he  understands  his  surroundings. 
Movements  tending  to  bring  strain  on  the  operated  parts 
are  to  be  restrained.  Too  vigorous  restraint  is  to  be 
avoided  if  possible,  as  it  tends  to  cause  the  patient  to 
struggle  harder.  In  case  of  violent  patients  a  sheet  may 
be  passed  over  the  thighs  and  another  over  the  shoulders 
and  fastened  to  the  sides  of  the  bed.  As  a  rule,  the  less 
the  minor  movements  of  the  extremities  are  interfered 
with,  the  more  tractable  the  patient  will  be. 

Anesthetic  Vomiting. — The  chief  danger  is  that  some  of 
the  vomited  matter  may  be  aspirated  into  the  bronchi 
and  set  up  a  foreign-body  pneumonia.  Vomiting  may  be 
prevented  to  a  great  extent  if  proper  precautionary 
measures  are  employed.  The  patient's  nose,  mouth,  and 
pharynx  should  be  thoroughly  cleansed  by  spraying  with 
an  astringent,  mildly  antiseptic  solution  an  hour  before 
anesthetization.  Should  catarrhal  condition  be  present, 
they  should  receive  special  attention.  Such  patients 
should  be  sprayed  every  three  or  four  hours  for  as  long  a 
time  as  the  preparation  of  the  case  will  admit.  Spraying 
the  throat  and  nose  with  a  2  per  cent,  solution  of  cocain 
directly  before  anesthetization  will  be  found  valuable 
in  lessening  the  irritability  of  the  mucus  membrane  to  the 
anesthetic,  and  thus  lessen  the  amount  of  secretion.  The 
patient's  head  is  turned  to  one  side  and  slightly  lowered 
during  and  after  anesthesia  to  favor  the  flow  of  secretion 
from  the  lower  angle  of  the  mouth  and  nose.  The 
stomach  should  be  empty,  but  the  patient  should  not 
have  been  too  long  deprived  of  food.  In  catarrhal 
conditions  of  the  stomach,  lavage  should  be  employed. 
A  sufficient  amount  of  the  anesthetic  is  to  be  administered 


Io6  OPERATING    ROOM    AND    THE    PATIENT. 

to  overcome  any  efforts  at  vomiting  during  the  course  of 
the  anesthetic.  Inspiration  of  food  or  mucus  is  apt  to 
cause  foreign-body  pneumonia.  The  struggles  of  an- 
under-anesthetized  patient  cause  subsequent  muscular 
discomfort  and  lassitude.  This  should  be  particularly 
avoided  in  patients  with  weak  heart.  The  secretions  of 
the  mouth  and  nose  should  be  removed  as  fast  as  they 
collect.  Stick  sponges  are  provided  for  this  purpose. 
The  admixture  of  oxygen  with  the  anesthetic  tends  to 
lessen  the  frequency  and  violence  of  the  vomiting. 

Treatment. — Oxygen  may  be  administered  for  from 
fifteen  to  thirty  minutes  following  the  withdrawal  of  the 
anesthetic,  with  excellent  results.  The  elevated  head 
and  trunk  position  tends  to  prevent  vomiting.  To  allay 
persistent  anesthetic  vomiting  cocain  hydrochlorate,  gr. 
■5^;  bismuth  subnitrate,  gr.  ^  ;  cerium  oxalate,  gr.  ^ ;  may 
be  given  dry  on  the  back  of  the  tongue,  every  half -hour 
for  four  doses.  Spraying  the  nose  and  throat  with  a  4. 
per  cent,  solution  of  cocain  will  prove  useful  in  some 
cases.  Frequently  rinsing  the  mouth  with  cool  water 
is  useful.  Ice  only  tends  to  keep  up  the  vomiting. 
Should  vomiting  continue,  lavage  may  be  practised.  If 
this  is  done  early  it  will  remove  mucus  and  anesthetic- 
soaked  secretions  from  the  stomach,  and  thus  tend  to 
prevent  retching  from  this  source. 

Character  of  the  Vomit. — The  vomited  matter  is  watery 
and  usually  colorless.  It  consists  of  mucus  and  stomach 
secretions.  At  times,  it  may  present  a  brilliant  green 
appearance,  due  to  admixture  with  bile.  It  rarely  lasts 
longer  than  a  few  hours  and  need  cause  no  anxiety, 
though  the  patient  may  feel  very  wretched. 

Persistent  Vomiting. — It  sometimes  happens  that  anes- 
thetic vomiting  is  prolonged  and  vomiting  persists  for 
several  days.  This,  when  not  traceable  to  other  causes, 
must  be  attributed  to  a  disturbed  motility  of  the  stomach 
itself,  due  to  nerve  disturbance.     The  character  of  the 


THE    AFTER    TREATMENT.  .     I07 

vomitus  does  not  differ  from  that  of  anesthetic  vomiting. 
Thin, mucous  secretions,  partially  bile  stained,  are  vomited 
frequently.  These  patients  continue  to  vomit  in  spite  of 
ordinary  treatment.  Systematic  lavage  of  the  stomach 
must  be  practised.  This  may  be  repeated  at  intervals 
of  four  hours  if  vomiting  persists.  Following  a  thorough 
cleansing  of  the  stomach  one-fourth  to  one-half  grain  of 
morphin  is  to  be  administered  hypodermatically.  In  this 
connection  it  is  well  to  remark  that  some  persons  have  an 
idiosyncrasy  to  morphin,  and  that  in  some  cases  the  drug 
will  itself  cause  persistent  nausea  and  vomiting.  In 
neurotic  individuals  the  use  of  counterirritation  over  the 
epigastrium  by  means  of  a  mustard  plaster,  or  even  the 
application  of  the  thermocautery,  may  be  useful.  I  have 
seen  one  case  which  vomited  for  several  weeks  after  an 
ovariotomy,  and  in  which  no  treatment  was  of  avail,  the 
vomiting  finally  stopping  spontaneously.  Nutrition  in 
the  cases  of  persistent  vomiting  is  maintained  by  nutrient 
enemata.  All  medication  by  the  mouth  is  withdrawn 
while  the  attacks  of  vomiting  continue.  When  feeding  by 
the  mouth  is  attempted,  half -ounce  doses  of  warm  fluids 
should  be  first  resorted  to  at  hour  intervals,  and,  if  these 
are  retained,  the  amount  may  be  gradually  increased. 
General  Appearance  of  the  Patient. — To  an  experienced 
eye  the  picture  which  the  patient  presents  is  of  great 
value.  In  an  uncomplicated  case  the  facial  expression 
will  be  contented  and  the  patient  will  welcome  the 
surgeon  with  a  smile.  There  may  be  some  minor  com- 
plaints, but,  on  the  whole,  the  picture  will  be  a  happy  one. 
Such  a  case  will  occasion  no  anxiety.  In  distention  the 
countenance  may  be  somewhat  troubled.  In  hemorrhage 
the  face  will  be  colorless,  lips  waxy,  pupils  dilated, 
respiration  rapid  and  shallow,  and  the  patient  thirsty, 
anxious,  and  restless.  In  peritonitis  the  face  will  be 
drawn  and  anxious,  the  eyes  somewhat  simken,  pupils 


I08  OPERATING    ROOM    AND    THE    PATIENT. 

dilated,  skin  covered  with  sweat,  and  the  patient  de- 
pressed; later  restlessness,  both  mental  and  physical, 
develop,  while  in  some  cases  a  peculiar  dusky  suffusion  of 
the  face  is  noted.  In  anuria  in  the  early  stages  there  is 
a  peculiar  glittering  of  the  eye  and  a  suffusion  of  the  face 
which  only  clinical  experience  can  recognize.  Later,  the 
picture  is  classic.  In  pnetimonia,  the  face  is  dusky  and 
the  respiration  rapid  and  labored.  Parotitis  is  self 
evident.  It  will  repay  the  surgeon  to  make  a  careful 
study  of  patients'  faces.  Often  the  first  clue  to  a  serious 
complication  may  be  thus  furnished.  On  the  other  hand, 
the  calm  face  and  general  contented  appearance  of  the 
case  will  furnish  grounds  for  a  good  prognosis  even  when 
serious  complications  are  threatening. 

Parotitis. — This  is  an  extremely  infrequent  complica- 
tion. I  have  seen  it  but  three  times  in  the  after-course  of 
several  thousand  laparotomies.  In  two  cases  typical 
symptoms  of  the  disease  presented  during  the  second 
week  following  operation  upon  the  adnexa.  Neither  case 
suppurated,  though  painful  swelling  persisted  for  several 
days.  In  one  case  the  disease  was  bilateral ;  in  the  other 
unilateral.  In  the  third  case  the  lesion  was  unilateral, 
developing  five  days  following  an  operation  for  extra- 
uterine pregnancy.  These  three  cases  recovered.  The 
only  treatment  employed  was  painting  the  overlying 
skin  with  tincture  of  iodin,  the  application  of  heat  to 
relieve  the  pain,  and  careful  and  frequent  cleansing  of  the 
mouth.  In  reported  cases  which  have  resulted  fatally 
and  have  been  submitted  to  microscopic  examination 
the  cause  seems  to  be  a  catarrh  of  Stenson's  duct  follow- 
ing infection  from  the  mouth.  In  such  cases  the  prog- 
nosis should  be  good.  The  lesion,  however,  may  be  but 
one  of  many  resulting  from  a  profound  septic  condition. 
Should  suppuration  ensue,  incision  and  free  drainage 
are  indicated.  There  seems  to  be  reason  to  suppose,  as 
some  authorities  indicate,  that  this  complication  occurs 


THE    AFTER    TREATMENT.  IO9 

after  abdominal  operations  more  frequently  than  after 
operations  elsewhere. 

Pain  is,  as  a  rule,  not  much  complained  of.  Neurotic 
patients  may  suffer  excruciating  agony  following  removal 
of  a  cystic  ovary.  Other  patients  will  suffer  but  slightly 
after  much  more  extensive  operations.  Morphin  should 
not  be  given  if  its  use  can  possibly  be  avoided,  especially 
in  laparotomy  cases.  Here,  even  small  doses  of  morphin 
are  apt  to  produce  distention.  Hypodermatic  injections 
of  hot  water  serve  in  many  cases.  Morphin  or  cocain 
habitues  are  to  be  watched  carefully.  Occasionally  it 
will  be  necessary  to  give  them  small  doses  of  that  drug 
to  which  they  have  been  accustomed.  The  pain  from 
the  wound  usually  subsides  in  twenty-four  hours.  Natur- 
ally if  the  patient  is  restless  pain  will  result  from  pulling 
upon  the  stitches.  Recurrence  of  the  pain  in  the  wound 
after  several  days'  quiescence  is  to  be  regarded  with 
suspicion  as  one  of  the  symptoms  of  infection.  Pain 
from  distention  is  treated  by  repeated  enemata.  In 
diffuse  abdominal  pain  the  ice  coil  will  prove  beneficial. 
Pain  persisting  after  the  patient  is  up  and  about  must  be 
inquired  into.  Not  infrequently  a  complete  change  of 
scene,  tonics,  and  an  out  of  door  life  will  cause  these 
vague  indefinite  pains  to  disappear. 

Thirst. — This  is  present  after  every  anesthetization,  and, 
in  spite  of  the  vomiting  which  the  imbibing  of  fluids 
cause,  patients  will  beg  for  water  to  quench  their  thirst. 
However,  since  we  have  employed  repeated  saline 
enemata  complaints  of  thirst  have  been  infrequent.  If 
much  blood  has  been  lost  thirst  will  be  a  prominent 
symptom. 

Treatment. — After  every  operation  necessitating  anes- 
thesia the  patient  should  receive  an  enema  of  from  one 
pint  to  one  quart  of  saline  solution  at  a  temperature  of 
110°  F.  Aside  from  its  other  advantages,  this  will 
result  in  a  great  diminution  in  the  thirst.     This  enema 


no  OPERATING    ROOM    AND    THE    PATIENT. 

is  usually  repeated  at  intervals  of  four  hours  for  four 
doses.  Small  quantities  of  cool  or  hot  fluids,  such  as 
peptonized  milk  or  broths,  may  be  given  as  soon  as 
anesthetic  vomiting  has  ceased  unless  the  operation  has 
been  one  involving  the  stomach.  If  the  latter,  feeding 
will  be  for  the  most  part  by  rectum  for  the  first  few  days. 
The  frequent  rubbing  of  the  mouth,  gtmis,  and  lips  with 
cool  water  will  prove  grateful.  Ice  should  be  prohibited, 
as  it  tends  to  increase  thirst  and  may  disorder  the  stomach 
and  induce  vomiting. 

The  nutrition  of  the  patient  must  be  borne  in  mind. 
For  the  first  few  hours  all  nourishment  by  the  stomach  is 
prohibited  on  account  of  the  irritability  of  that  organ 
caused  by  the  anesthetic.  As  soon  as  anesthetic  vomiting 
has  ceased,  however,  liquid  food  may  be  given  by  mouth. 
Peptonized  milk  or  light  broths  are  best  for  the  first 
twenty-four  hours,  the  doses  being  so  graded  as  gradually 
to  accustom  the  weakened  stomach  to  retain  larger 
and  larger  doses  at  more  extended  intervals  until  at  the 
end  of  twenty-four  or  at  the  latest  forty-eight  hours  full 
fluid  diet  is  reached.  Following  this,  stronger  soups  and 
farinaceous  foods  are  given  for  a  few  days,  and  finally 
meat  and  vegetables.  Patients  lying  in  bed  do  not 
require  as  large  a  quantity  of  food  as  those  who  are 
walking  about.  Overloading  the  stomach  is  to  be 
avoided.  The  character  of  the  food  should  be  such  as  to 
be  readily  assimilable.  Flatus-producing  foods  4re  to  be 
avoided.  Emaciated  patients  receive  additional  nourish- 
ment by  rectum.  Care  must  be  exercised  in  the  selection 
of  a  diet  and  individual  tastes  and  idiosyncrasy  consulted 
as  much  as  possible.  The  appetite  does  not  return,  as  a 
rule,  for  one  or  two  days.  The  tongue  is  coated  and  the 
breath  foul.  The  odor  of  the  anesthetic  clings  to  the 
patient.  Particularly  is  this  the  case  if  bromid  of  ethyl 
has  been  used  preliminarily.  The  odor  is  that  of  garlic, 
and  is  disagreeable  to  the  average  patient.     The  stomach 


THE    AFTER    TREATMENT.  Ill 

is  distended  and  the  eructation  of  gas  is  common.  Nausea 
persists  after  actual  vomiting  has  ceased.  It  is  not 
necessary'  to  force  the  feeding.  The  patient's  inclinations 
are  the  best  guide  as  to  the  amount  of  nourishment  that 
is  needed  in  the  first  few  days.  The  diet  should  be  a 
varied  one  as  soon  as  the  patient  is  able  to  digest  properly. 
The  time,  material,  and  amount  of  each  meal  should  be 
designated  by  the  surgeon  in  charge.  Youth  and  old  age 
require  the  greatest  care.  In  case  of  continued  loss  of 
appetite  a  search  should  be  made  for  the  cause,  which 
may  prove  to  be  an  unfavorable  condition  of  the  wound. 
The  digestion  of  the  food  should  be  ascertained.  Con- 
stipation and  flatulence  are  watched  for  and  remedied  as 
far  as  possible  by  diet.  Apple  sauce,  prunes,  grapes, 
orange  and  lemon  juice,  and  A^ichy  water  will  be  found  of 
value  in  this  regard.  Lack  of  accustomed  exercise  will 
account  for  constipation  in  many  cases.  Massage  will 
often  be  of  benefit.  Enemata,  either  of  soapsuds  and 
warm  water  or  containing  spirit  of  turpentine,  ox-gall, 
lac  asafoetida,  or  alum,  according  to  the  severity  of  the 
case,  are  indicated  if  a  natural  movement  does  not  result 
in  forty-eight  hours.  Distention  is  relieved  by  the  pas- 
sage of  the  rectal  tube  as  required,  and  by  the  elevated 
head  and  trunk  position.  In  elderly  persons  suffering 
from  atony  of  the  intestinal  w^all,  treatment  of  flatulence 
must  be  vigorous  and  initiated  early.  Calomel  and 
salines  may  be  necessary  to  produce  thorough  evacuation. 
A  simple  dose  of  castor  oil  will  often  prove  beneficial. 
During  convalescence,  massage,  both  general  and  local, 
is  of  value.  Regulate  the  diet.  Give  a  natural  cathartic 
water,  or  one-half  teaspoonful  of  the  fluid  extract  of 
cascara  (bitterless)  may  be  taken  at  bedtime.  This  may 
be  advantageously  combined  with  the  fluid  extract  of 
licorice.  In  any  event,  the  bowels  should  move  once 
daily  while  the  patient  is  in  bed,  with  the  exception  of  the 
first  day.     If  regular  movements  do  not  occur,  intestinal 


112  OPERATING    ROOM    AND    THE    PATIENT. 

toxemia  is  apt  to  develop.  This  is  shown  by  a  furred, 
condition  of  the  tongue,  foul  breath,  distention,  abdominal 
discomfort,  and  a  rise  of  temperature.  Following  en- 
emata  or  a  cathartic  the  bowels  move  freely  and  the 
unpleasant  symptoms  subside.  In  the  care  of  the 
bowels  in  operations  involving  the  integrity  of  the  intes- 
tinal wall  reliance  must  be  placed  upon  enemata.  No 
cathartic  is  to  be  given  until  the  tenth  day,  except  in  the 
case  of  an  impending  peritonitis.  Fecal  impaction  may 
result  if  proper  attention  is  not  paid  to  the  movements. 
This  will  necessitate  spooning  the  hardened  fecal  masses 
from  the  rectum  and  the  administration  of  a  course  of 
calomel  and  castor  oil. 

Dilatation  of  the  Stomach. — This  postoperative  com- 
plication is  exceedingly  rare.  Several  cases  have  been 
reported  by  Dr.  P.  Miller  ("  Deutsche  Zeitschrift  fiir 
Chirurgie,"  vol.  Ivi,  Nos.  5  and  6,  p.  486,  1900).  The 
dilatation  is  caused  by  the  wedging  of  the  duodenum 
between  the  duodeno-jejunal  juncture  and  superior 
mesenteric  artery.  In  most  cases  this  has  followed 
laparotomy,  but  may  occur  after  operations  upon  other 
portions  of  the  body.  Vomiting  is  persistent  and  profuse, 
becoming  grayish  brown  and  later  black.  It  has  no  fecal 
odor.  The  abdomen  is  not  distended  and  there  is  no 
pain.  There  is  little  gas  or  fecal  matter  passed.  There 
is  no  rise  in  temperature,  no  marked  increase  in  pulse  rate, 
or  no  severe  general  malaise.  Diagnosis  is  only  possible 
after  determining  the  dilation  of  the  stomach.  Autopsy 
shows  the  stomach  and  duodenum  markedly  dilated. 
The  pelvis  is  filled  by  the  collapsed,  ribbon-like  remainder 
of  the  small  intestine.  The  diagnosis  of  this  complication 
is  difficult  on  account  of  its  rare  occurrence.  A  few  of 
these  cases  are  said  to  have  been  diagnosed  during  life 
and  saved  by  prompt  measures.  The  treatment  consists 
in  emptying  and  washing  out  the  stomach.  The  patient 
is   turned   on   the   stomach   and   the   lower   extremities 


THE    AFTER    TREATMENT.  II3 

elevated  to  empty  the  pelvis  of  the  intestinal  coils  and 
thus  relieve  tension  on  the  duodenum.  One  such  case 
has  come  under  our  observation,  but,  in  spite  of  early 
diagnosis,  repeated  washing  out  of  the  stomach,  and 
change  of  position,  death  ensued.  The  autopsy  verified 
the  diagnosis. 

The  general  rules  of  hygiene  must  be  carried  out.  The 
room  and  surroundings  are  to  be  made  as  pleasant  as 
possible.  There  must  be  plenty  of  fresh  air.  The  bed- 
clothes must  be  clean  and  changed  frequently.  The 
patient's  skin  must  be  kept  clean  by  sponge  baths.  Care 
is  taken  that  the  patient  is  not  chilled.  Vaginal  douches 
are  given  as  required.  The  teeth,  hair,  and  nails  should 
receive  attention.  It  will  be  well  if  the  attending  phy- 
sician gives  these  matters  his  personal  attention  and 
sees  that  his  orders  are  carried  out  by  the  nurse.  Not 
only  is  the  patient  kept  comfortable,  but  wounds  will  heal 
more  quickly,  if  hygienic  conditions  are  good.  General 
massage  may  be  given.  This  will  increase  the  action  of 
the  skin  and  tend  to  prevent  pressure  sores. 

The  urine  must  be  watched  carefully.  In  all  cases  the 
total  quantity  passed  in  the  first,  second,  and  third 
twenty-four  hours  is  recorded.  A  sample  of  the  mixed 
urine  of  each  day,  together  with  a  slip  bearing  the 
patient's  name,  date,  and  the  amount  passed,  is  sent  to 
the  pathologist  for  chemic  and  microscopic  examination. 
The  same  procedure  is  carried  out  on  the  tenth  day.  In 
cases  in  which  kidney  complications  occur  the  urine  is 
examined  more  frequently. 

Albuminuria  may  develop  as  a  result  of  the  anesthetic. 
This  will,  as  a  rule,  disappear  by  the  tenth  day,  and  is  not 
significant  of  a  kidney  lesion.  Should  diabetes  or  renal 
disease  develop,  the  urinalysis  will  give  the  first  clue 
and  treatment  may  be  begun  promptly.  The  urinalysis 
report  should  comprise  the  name  of  the  patient,  date, 
quantity    passed    in    twenty -four    hours,    color,    odor, 


114  OPERATING    ROOM    AND    THE    PATIENT. 

reaction,  specific  gravity,  the  presence  and  amount  of 
albumin  and  sugar,  the  amount  of  urea,  the  presence  of 
bile,  the  relative  amount  of  chlorid  and  peptones,  the 
deposits  on  standing,  crystals,  casts,  and  other  microscopic 
findings.  The  report  is  signed  and  filed  with  the  other 
records  going  to  make  up  the  history  of  the  case. 

Cystitis  is  apt  to  follow  cases  in  which  the  catheter  is 
employed,  particularly  in  females.  With  -care  and 
cleanliness  in  the  technic,  catheter  cystitis  should  rarely 
occur.  Early  catheterization  is  of  value  as  showing 
whether  the  kidneys  are  properly  functioning    or    not. 

Anuria  may  occur  after  any  anesthetization,  but  is 
more  likely  to  occur  after  operation  involving  the  urinary 
apparatus;  next  in  frequency  after  laparotomies.  It 
may  be  caused  by  the  absorption  of  strong  antiseptics, 
such  as  carbolic  acid  and  bichlorid  of  mercury.  This  is 
one  reason  why  strong  antiseptics  should  not  be  employed. 

Retention  of  Urine. — The  bladder  must  not  be  allowed 
to  become  distended.  If  the  patient  has  not  urinated 
voluntarily  in  ten  to  twelve  hours  the  catheter  is  used. 
It  is  not  necessary  to  catheterize  until  this  time,  provided 
the  bladder  has  been  emptied  prior  to  the  operation,  as 
the  amount  of  urine  passed  in  the  first  twelve  hours  is 
never  sufficient  unduly  to  distend  the  bladder.  A  su- 
prapubic examination  of  the  bladder  is  useful  as  show- 
ing whether  the  use  of  the  catheter  is  imperative.  Sub- 
sequent catheterization  may  be  done  every  six  or  eight 
hours  as  indicated.  It  should  be  discontinued  as  soon  as 
possible. 

Placing  the  patient  in  a  hot  bath,  applying  hot  com- 
presses, turning  the  patient  on  the  side,  or,  if  feasible, 
allowing  the  patient  to  get  out  of  bed  may  cause  the 
urine  to  be  passed  voluntarily. 

Catheterization  in  the  Female. — The  operator's  or 
nurse's  hands  should  be  scrubbed  and  thoroughly  dis- 
infected.    The  mucous  membrane  and  skin  surrounding 


THE    AFTER    TREATMENT.  II5 

the  urethral  orifice  should  be  cleansed  with  sterile  water, 
followed  by  a  swabbing  with  boro-salicylic  solution. 
The  patient  should  lie  on  her  back  with  the  thighs  well 
separated  and  the  limbs  flexed  at  the  knees.  The  parts 
should  be  well  exposed  to  a  good  light.  It  is  pre- 
ferable to  use  a  glass  catheter  on  the  score  of  cleanliness. 
If  such  a  one  is  not  at  hand  a  silver  instrument  may  be 
used.  It  is  rendered  aseptic  by  boiling  and  is  lubricated 
with  olive  oil  or  vaselin.  The  instrument  is  gently 
inserted  within  the  urethral  orifice  and  pushed  without 
force  along  the  urethra.  As  soon  as  the  bladder  is  entered 
urine  will  flow  through  the  catheter  into  a  vessel  held  to 
receive  it.  Following  catheterizing,  there  may  persist 
a  slight  degree  of  vesical  irritability.  To  quiet  this, 
twenty  drops  of  spirit  of  nitrous  ether  may  be  given  everv^ 
two  or  three  hours  until  the  irritability  subsides.  Salol 
in  five-grain  doses  may  also  be  given.  The  danger  of 
infection  of  the  bladder,  ureters,  or  kidneys  must  be  borne 
in  mind  at  every  catheterization. 

The  temperature  is  taken  every  four  hours  for  the  first 
three  days;  later  night  and  morning  in  ordinary  cases. 
In  abdominal  cases  the  temperature  is  taken  every  four 
hours  for  the  first  ten  days ;  then  night  and  morning  until 
convalescence  is  well  under  way.  In  septicemic  and 
complicated  cases  the  temperature  is  taken  every  four 
hours  until  all  danger  is  passed.  In  cases  of  septic 
abdominal  complications,  whether  operative  or  under 
observation,  the  temperature  is  taken  every  hour.  Di- 
rectly after  the  operation  the  temperature  may  be 
subnormal.  This  may  occur  at  times  during  the  after- 
treatment.  Of  itself  it  need  not  occasion  alarm.  If 
the  wound  pursues  an  aseptic  course  the  temperature  will 
not  vary  to  any  marked  degree.  It  may  be  normal  or  as 
high  as  100°  F.,  but  will  pursue  an  even  course.  A  slight 
rise  to  100°  F.  or  ioi°  F.  occurring  in  the  first  few  days 
prior  to  the  occurrence  of  a  bowel  movement  is  not  a 


Il6  OPERATING    ROOM    AND    THE    PATIENT. 

source  of  anxiety.  The  cause  is  found  in  intestinal 
fermentation.  This  causes  an  autointoxication.  Auto- 
intoxication may  not  be  due  to  partial  reabsorption  of 
excrementitious  matter  in  the  intestinal  canal  alone,  but 
may  also  be  due  to  lessened  activity  of  the  skin,  lungs, 
kidneys,  and  liver.  Should  the  tongue  be  furred,  breath 
bad,  a  bad  taste  in  the  mouth,  headache,  anorexia,  or 
malaise  be  present,  and  the  bowels  be  closed,  together 
with  a  slight  rise  of  temperature,  moving  the  bowels 
promptly  causes  a  return  to  the  normal  course.  During 
the  first  twenty-four  hours  the  temperature  may  rise  to 
ioo°,  ioi°,  or  even  102°  F.  in  aseptic  cases.  This  re- 
active fever  is  commonly  known  as  aseptic  fever.  This 
rise  in  temperature  is  gradual ;  reaches  its  maximum  in  a 
few  hours,  in  any  event  by  the  end  of  the  first  twenty- 
four  hours ;  and  is  rarely  accompanied  by  a  chill.  There 
is  a  corresponding  increase  in  pulse-rate.  The  patient's 
face  is  flushed,  the  eyes  are  bright,  and  there  is  more  than 
the  usual  amount  of  thirst.  These  symptoms  subside  in  a 
few  hours,  or  in  any  case  by  the  end  of  the  second  twenty- 
four  hours.  They  need  occasion  no  alarm.  Since  we 
have  employed  saline  enemata  as  a  routine  procedure  we 
have  not  noted  as  high  a  "reactive  fever"  as  formerly. 
Any  sharp  deviation  from  the  normal  course  of  wound 
temperature  is  to  be  regarded  with  suspicion.  Normal 
wound  temperature  may  not  be  normal  temperature  in  the 
usual  sense,  but  may  be  99°  to  loo"^  F.  Actual  normal 
temperature,  98.4°  F.,  may  not  be  reached  until  the  tenth 
day.  A  slight  rise  of  temperature  indicating  a  slight 
local  disturbance  is  not  incompatible  with  primary  union. 
Every  rise  of  temperature  has  a  cause,  and  this  cause 
must  be  sought  out,  and,  if  harmful,  removed.  Arise  in 
temperature  in  the  first  twenty-four  hours,  while  probably 
due  to  the  absorption  of  nucleins  and  albumoses  (aseptic 
fever) ,  may  be  due  to  pneumonia,  bronchitis,  or  nephritis. 
In  the  latter,  however,  there  will  be  other  symptoms  which 


THE    AFTER    TREATMENT.  II7 

will  lead  to  a  correct  diagnosis.  Tension  of  the  pulse, 
headache,  wandering  delirium,  and  muscular  twitching 
will  establish  the  diagnosis  of  a  renal  lesion.  Physical 
examination  of  the  chest  and  careful  urinalysis  will  aid 
in  establishing  the  cause  of  the  fever.  Fever  occurring 
after  a  lapse  of  two  or  three  days  indicates  superficial 
wound  infection,  if  the  bowels  have  moved.  If  not, 
intestinal  fermentation  may  be  ruled  out  by  moving  the 
bowels.  Fever  occurring  in  the  second  week  usually 
indicates  infection  of  the  deeper  tissues,  stitch  abscess. 
Fever  due  to  causes  other  than  those  mentioned  may  occur. 
Operative  cases  have  no  more  immunity  from  the  usual 
causes  of  fever — typhoid,  malaria,  diphtheria,  etc. — 
than  other  persons.  As  a  rule,  a  temperature  which 
continues  high,  associated  with  rapid  pulse  from  the  time 
of  operation,  indicates  severe  general  infection. 

The  pulse  should  be  just  as  carefully  watched  as  the 
temperature.  Any  variation  from  the  normal  frequency, 
rhythm,  and  tension  is  noted.  It  is  studied  in  con- 
nection with  the  temperature.  After  severe  operations 
or  prolonged  anesthetizations  a  rapid  pulse  is  the  rule. 
This  may  persist  for  forty-eight  hours,  but  so  long  as  it 
does  not  increase  in  rapidity  and  so  long  as  the  general 
condition  of  the  patient  is  good  there  will  be  no 
cause  for  anxiety.  The  pulse  should  be  full  and 
compressible.  In  cases  pursuing  a  normal  wound  course, 
the  same  relation  will  be  maintained  throughout  between 
the  pulse  and  the  temperature.  The  respiration  is  also 
carefully  watched  and  recorded.  It  is  studied  in  its 
relation  to  the  temperature  and  pulse.  Its  type,  costal 
or  abdominal ;  depth,  deep  or  shallow ;  rhythm,  regular  or 
irregular;  rate,  rapid  or  slow;  equality  of  expansion  of 
each  side  of  the  chest,  whether  painful  or  not;  and  its 
other  characters  are  noted.  If  any  variation  from  the 
normal  occurs,  a  prompt  search  for  the  cause  is  insti- 
tuted.     Physical  examination  to  be  thorough  must  in- 


Il8  OPERATING    ROOM    AND    THE    PATIENT. 

elude  not  only  the  anterior  and  lateral  chest  wall,  but 
also  the  posterior  region.  It  is  here  that  pneumonic 
processes  (hypostatic  pneumonia)  begin.  After  abdominal 
operations  the  respiration  may  be  increased  to  twenty- 
four  and  remain  so  for  several  days. 


CHAPTER  VII. 
INSTRUMENTS. 

I.  Articles  Required  for  All  Operations. 

Ligature  catgut,  medium,  and  fine. 

Chromic  catgut,  medium  and  fine. 

Silk,  medium  and  fine. 

Silkworm-gut. 

Straight,  sharp-pointed  scissors. 

Long,  straight,  spear-pointed  needle. 

Medium-sized,   curved,   cutting-edge  needle. 

Soft -rubber  male  catheter,  Xo.  15  F. 

Glass  female  catheter. 

2   irrigators,    nozzles,    tubing,   various    sized    glass 

connections. 
Safety  pins. 
Basin  for  specimens. 

1  probe. 

II.  Operations  upon  the  Scalp  (preparatory^  to  trephining 
and  for  operations  upon  the  soft  parts). 

2  protectors. 
6  towels. 
Junker  apparatus. 

1  three  foot  length  of  small-sized  rubber  tubing  (for 

tourniquet). 

2  scalpels. 

2  pair  anatomic  forceps. 
12  Kocher  clamps. 
2  blunt  hook  retractors. 

18  medium-sized,  half-curved,  cutting-edge  needles 
(threaded  in  pairs  with  silkworm  gut). 
-    119 


I20  OPERATING    ROOM    AND    THE    PATIENT. 

I    pair    curved-on-the-flat,    blunt-pointed    scissors. 
4  gauze  compresses. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

2  three-inch  gauze  bandages. 
30  hand  sponges. 

12  stick  sponge  holders. 

III.  Trephining  and  Craniectomy  (in  addition  to  List  II). 
I  cyrtometer. 

I  periosteal  elevator. 

1  set  trephines. 

Saline    irrigation    (to    keep    operative    field    clear). 

2  craniectoray  forceps. 
I  rongeur  forceps. 

I  set  large  chisels. 

I  mallet. 

I  aspirating  syringe  and  needle. 

Basin  of  saline   solution,    100°   F.    (for  temporarily 

removed  bone). 
I  telephonic  brain  probe. 

1  small,  narrow-bladed  scalpel. 

2  pairs  mouse-tooth  forceps. 

2  small,  full-curved,  cutting-edge  needles  (threaded 
with  fine  chromic  gut,  for  suturing  dura). 

1  needle  holder. 

Green  silk  protective  (for  drains). 

2  three-inch  plaster-of- Paris  bandages,  salt  solution, 

and  additional  plaster. 

IV.  Excision  of  the  Trigeminus  (in  addition  to  Lists  II 

and  III). 
2    Crile    clamps    (for    temporary    occlusion    of    the 
carotids). 

1  brain  retractor  with  cold  electric  light. 
50  small  stick  sponges. 

V.  Excision  of  the  Upper  Jaw. 

2  protectors. 
6  towels. 


INSTRUMENTS  12  1 

Junker's  apparatus. 

Tracheotomy  set  (List  XIII). 

Trendelenburg  cannula. 

2  tooth-forceps. 

2  full-bellied  scalpels. 

2  pairs  anatomic  forceps. 
I  periosteal  elevator. 

12  Kocher  clamps. 

I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

I  set  large  chisels. 

I  mallet. 

I  lion- jaw  forceps. 

I  straight  bone-cutting  forceps. 

I  angular  bone-cutting  forceps. 

1  rongeur  forceps. 

3  blunt  hook  retractors. 

2  Volkmann  sharp  spoons. 

2  medium-sized,  full-curved,  cutting-edge  needles 
(threaded  with  catgut  loop  sutures). 

I  twelve-inch  square  of  zinc  oxid  gauze. 

12  one-inch  zinc  oxid  packing  strips. 

12  medium-sized,  half-curved,  cutting-edge  needles 
(threaded  in  pairs  with  silkworm-gut). 

Thermocautery . 

I  medium-sized,  full-curved,  cutting-edge  needle 
(threaded  with  silk  for  tongue  suture). 

4  gauze  compresses. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

2  three-inch  gauze  bandages. 
12  stick  sponge  holders. 

50  stick  sponges. 
50  hand  sponges. 

lodoform-collodion,  glass,  and  brush. 
VI.  Resection  of  the  Lower  Jaw  (in  addition  to  List  V). 

1  chain  saw  and  carrier. 

2  Gigli  saws. 


122  OPERATING    ROOM    AND    THE    PATIENT. 

VII.  opening  the  Mastoid. 

2  protectors. 

6  towels. 

2  scalpels. 

2  blunt  hook  retractors. 

I  periosteal  elevator. 

6  Kocher  clamps. 

I  set  mastoid  chisels. 

I  set  mastoid  gouges. 

I  mallet. 

1  small  trephine. 

2  Volkmann  sharp  spoons. 
I  small  sinus  curette. 

I  probe. 

I  grooved  director. 

I  pair  curved-on-the-flat,  blunt-pointed  scissors. 
Boro-salicylic  irrigation. 
2o  hand  sponges. 
30  small  stick  sponges. 
I  one-inch  zinc  oxid  packing  strip. 
4  medium-sized,    half-curved,   cutting-edge    needles 
(threaded  in  pairs  with  silkworm-gut). 

3  gauze  compresses. 

1  twelve-inch  square  of  nonabsorbent  cotton. 

2  three-inch  gauze  bandages. 
VIII.  Harelip. 

2  protectors. 

6  towels. 

I  tongue-forceps. 

I  tongue-depressor. 

1  mouth-gag. 

2  medium-sized,    half -curved,    cutting-edge    needles 

(threaded  with  silk,  for  traction  sutures). 
I  small,  narrow-bladed  scalpel. 

1  straight,  sharp-pointed  bistoury. 

2  pair  mouse-tooth  forceps. 


INSTRUMENTS.  12  3 

I  pair  curved-on-the-flat,  sharp-pointed  scissors. 
6  medium-sized,    half-curved,    cutting-edge  needles 

(threaded  with  silk). 
6  small,  half -curved,  cutting-edge  needles  (threaded 

with  silk). 
I  needle  holder. 

1  pair  small  hook  retractors. 
6  pointed  artery  clamps. 

12  hand  sponges, 
lodoform-collodion,  glass,  and  brush. 

2  narrow  strips  of  adhesive  plaster   (to  relieve  ten- 

sion) . 
IX.  Staphylorrhaphy  and  Uranoplasty. 
2  protectors. 
6  towels. 
I  Whitehead  gag. 

1  mouth-gag. 

2  cheek  retractors. 

1  tongue-depressor. 

12  stick  sponge  holders. 
50  stick  sponges. 

2  single  tenacula. 

I  narrow,  flat-bellied  scalpel  (for  section  of  levator 
palati) . 

1  small-bladed  scalpel  (for  paring  edges  of  cleft). 

2  pair  long-handled,  mouse-tooth  forceps. 

I  pair  long-handled,  curved-on-the-flat,  sharp-pointed 

scissors. 
I  dull-edged  periosteal  elevator  bent  at  a  right  angle. 
I  sharp-edged   periosteal   elevator  bent   at   a   right 

angle. 

3  small,  half-curved,  cutting-edge  needles  (threaded 

with  silk  loops,  for  guide  suture). 
12  paraffin  silk  sutures. 
6  artery  clamps  (to  attach  to  sutures). 
I  long-handled  needle  holder. 


124  OPERATING    ROOM    AND    THE    PATIENT. 

I  right  Spiral  curved,  sharp-pointed  aneurysm  needle. 
I  left  spiral  curved,  sharp-pointed  aneurysm  needle. 
X.  Tonsillotomy. 
I  large  protector. 
6  towels. 
I  mouth-gag. 
I  tongue  depressor. 
I  pair  tenaculum  forceps. 
I  pair  long-handled,  curved-on-the-fiat,  blunt-pointed 

scissors. 
I  curved,  probe-pointed  bistoury. 

1  tonsillotome. 

2  stick  sponge  holders. 
12  stick  sponges. 

Ice  water,  tumbler,  and  pus  basin. 
XI.  Adenoids. 
I  large  protector. 
6  towels. 
I  mouth-gag. 

1  tongue  depressor. 

2  Gottstein  curettes. 

I  pair  Lowenbury's  forceps. 
6  sponge  holders. 
2o  stick  sponges. 
I  uvula  retractor. 
I  No.  28  F.  sound. 

Solution  of  adrenalin  chlorid,  i-iooo. 
XII.  Deviated  Septum. 
I  large  protector. 
6  towels. 
I  mouth-gag. 
I  tongue  depressor. 
6  sponge  holders. 
20  stick  sponges. 

Solution  of  adrenalin  chlorid,  i-iooo. 
Small  pieces  of  cotton  on  wooden  applicators. 


INSTRUMENTS.  12  5 

2  Douglas  knives. 

I  Mial  saw. 

I  Curtis  saw. 

I  Bosworth  saw. 

I  elevator. 

I  pair  Asch's  scissors. 

I  pair  Asch's  compressors. 

I  Douglas  perforator. 

1  set  Asch's  splints. 

XIII.  Tracheotomy. 

2  protectors. 
6  towels. 

1  full-bellied  scalpel. 
18  Kocher  clamps. 

2  hook  retractors. 

2  pairs  anatomic  forceps. 

2  single  tenacula. 

I  flat-bellied  scalpel. 

I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

I  pair  curved-on-the-fl[at,  sharp-pointed  scissors. 

I  cartilage-cutting   forceps    (for   enlarging   tracheal 

opening) . 
I  set  tracheotomy  tubes. 
Tapes  for  tube. 

3  medium-sized,   half -curved,    cutting-edge    needles 

(threaded  with  silk). 
3  medium-sized,    half-curved,    cutting-edge    needles 

(threaded  with  silk). 
Flexible  applicator  and  absorbent  cotton. 
20  hand  sponges. 
I  needle  holder. 
20  small  stick  sponges, 
6  stick  sponge  holders. 

XIV.  Cervical  Adenectomy. 

I  small  flat  sand-bag   (placed  under  the  shoulders 
to  extend  the  neck). 


126  OPERATING    ROOM    AND    THE    PATIENT. 

2  protectors. 

6  towels. 

2  scalpels  (dissecting  handles). 

24  Kocher  clamps. 

12  pointed  artery  clamps. 

2  pairs  anatomic  forceps. 

2  pairs  curved-on-the-flat  and  blunt-pointed  scissors. 

2  small,  smooth  retractors. 

2  blunt  hook  retractors. 

2  Volkmann  sharp  spoons. 

1  needle  holder. 

6  medium-sized,    half-curved,    cutting-edge    needles 
(threaded  in  pairs  with  silkworm-gut). 

2  long,    straight,    spear-pointed    needles    (threaded 

w4th  silk  for  subcuticular  sutures). 

1  medium-sized,    half-curved,    cutting-edge    needle 

(threaded  with  silk  for  subcuticular). 
12  stick  sponge  holders. 
50  stick  sponges. 
6  gauze  compresses  (shaken  out). 

2  one-inch  zinc-oxid  strips  (in  drainage  cases). 

2  four-inch   fenestrated  rubber  tubes    (in   drainage 
cases). 

2  twelve-inch  squares  of  nonabsorbent  cotton. 

3  three-inch  gauze  bandages. 

2  three-inch  plaster-of- Paris  bandages  (in  children) . 
XV.  Goiter  (in  addition  to  List  XIV). 

4  aneurysm   needles    (threaded   with   medium-sized 

catgut). 
Thermocautery. 
XVI.  Cut  throat. 

Combine  Lists  XIII  and  XIV. 
XVII.  Occlusion  of  the  Carotids,  Temporary  or  Permanent. 
List  XIV,  minus  sharp  spoons  and  drainage. 
2  aneurysm  needles  (threaded  with  two  strands  of 
medium-sized  catgut). 


INSTRUMENTS.  1 27 

2  Crile  clamps  (for  temporary  occlusion). 

Paraffin   injection   syringe,    paraffin,   alcohol   lamp, 

basin  of  hot  water   (in  occlusion  of  terminals 

of  external  carotid). 
XVIII.  Amputation  of  the  Breast  (radical  operation  for 

carcinoma). 

1  fiat  sand-bag. 

2  large  protectors. 

I  arm  and  hand  protector. 

I  bandage  (for  scouring  arm). 

24  towels. 

I  towel  wringer. 

Hot  saline  in  pitcher  (for  hot  towels). 

3  full-bellied  scalpels. 

1  small  scalpel. 
50  artery  clamps. 

2  pairs  anatomic  forceps. 

2  pairs  curved-on-the-fiat,  blunt-pointed  scissors. 

I  pair  blunt  hook  retractors. 

I  pair  small,  smooth  retractors. 

I  aneurysm  needle. 

I  single  tenaculum. 

50  large,  half -curved,  cutting-edge  needles  (threaded 

in  pairs  with  silkworm-gut). 
I  long,  straight,  spear-pointed  needle  (threaded  with 

silk  for  subcuticular  suture). 
I  skin-grafting  set  (List  LXXX). 
75  hand  sponges. 

12  gauze  compresses  (shaken  out). 
>    2  squares  nonabsorbent  cotton. 
I  breast  binder. 

I  three-inch  Canton-flannel  bandage. 
12  safety  pins. 
XIX.  Empyema  (resection  of  rib) . 

1  fiat  sand-bag. 

2  protectors. 


128  OPERATING    ROOM    AND    THE    PATIENT. 

6  towels. 

Exploring  syringe. 

Stethoscope  (Bowles). 

2  scalpels. 

12  artery  clamps. 

2  blunt  hook  retractors. 

I  periosteal  elevator. 

I  costotome. 

I  angular,  bone-cutting  forceps. 

I  rongeur  forceps. 

1  bone-grasping  forceps. 

2  Volkmann  sharp  spoons  (in  caries  cases). 

I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

I  pointed  artery  clamp  (for  opening  pleura). 

I  blunt  curette. 

6  stick  sponge  holders. 

2o  stick  sponges. 

20  hand  sponges. 

I  eight-inch  large  caliber  drainage  tube  and  glass 
connection  (for  subaqueous  drainage). 

8  medium-sized,  half-curved,  cutting-edge  needles 
(threaded  in  pairs  with  silkworm-gut). 

I  medium-sized,  half-curved,  cutting-edge  needle 
(threaded  with  silk  to  retain  tube  in  place). 

Boro-salicylic  and  saline  irrigation  (in  case  of  fibrin- 
ous masses). 

3  gauze  compresses  (slit  to  allow  tube  to  emerge). 

4  adhesive  plaster  taped  straps. 
I  chest  binder. 

12  safety  pins.  '' 

ABDOMINAL  OPERATIONS. 

XX.  Accessories  (extra-abdominal). 

I  laparotomy  sheet  or  2  protectors. 
12  towels. 
4  safety  pins. 


INSTRUMENTS.  1 29 

XXI.  Laparotomy  Incision  (making). 
2  single  tenacula  (to  steady  the  skin). 

1  skin  knife,  small  bellied. 

2  pairs  anatomic  forceps. 
6  pairs  artery  clamps. 

I  pair  curved-on-the-flat,  blunt -pointed  scissors. 
I  pair  narrow  retractors. 
XXII.  Laparotomy  Incision  (retraction). 

1  self-retaining  retractor,  3  sets  of  blades. 

2  medium-sized  retractors. 
2  large  retractors. 

2  small  retractors. 
XXIII.  Accessories  (intra-abdominal). 

12  crash  laparotomy  sponges. 

12  gauze  laparotomy  sponges. 

50  stick  sponges. 

12  stick  sponge  holders. 

Woelfler's  solution  and  medicine  dropper. 

I  ligature  carrier. 

I  basin  of  hot  bichlorid. 

I  basin  of  hot  saline. 

Towels,  towel  wringer,  and  pitcher  of  hot  saline. 
XXIV.  Articles  Required  in  Drainage  Cases. 

I  quart   equal  parts   hydrogen  peroxid  and  sterile 
water  (can  be  used  slightly  warm). 

1  Chamberlain  douche  nozzle. 
Saline  solution,  120°  F. 

2  curved,  fenestrated,  glass  drainage  tubes. 
Plain  wicking. 

Cigarette  drains. 

Zinc  oxid  wicking. 

Gauze  strips,  two  and  four  inches  wide. 

Rubber  dam  (to  slip  over  tubes  and  so  protect  wound 

dressing) . 
Rubber  tubing  (in  gall-bladder  cases  and  for  lateral 

drain  in  appendicitis  with  abscess). 


130  OPERATING    ROOM    AND    THE    PATIENT. 

I  uterine  dressing  forceps. 

I  narrow-bladed  scalpel  (for  making  accessory  drain- 
age opening). 

I  straight,  blunt-pointed  bistoury  (for  making  ac- 
cessory drainage  opening). 

I  pair  long-handled,  sharp-pointed,  curved  scissors 
(for  vaginal  drainage). 

I  pair  long-handled,  blunt-pointed,  curved  scissors 
(for  vaginal  drainage) . 

I  large  glass  syringe. 

I  vulvar  pad  and  T-bandage  in  cases  drained  per 
vaginam. 
XXV.  Laparotomy  Incision  (closing). 

18  large,  half -curved,  cutting-edge  needles  (threaded 
in  pairs  with  silkworm-gut). 

12  artery  clamps. 

8  Halsted  clamps  for  the  peritoneum. 

I  pair  cur ved-on-t he-flat,  blunt-pointed  scissors. 

1  medium-sized,  half-curved,  round  needle  (threaded 

with  loop  suture  of  catgut,  for  purse-string  su- 
ture of  peritoneum). 

2  medium-sized,    half -curved,    cutting-edge    needles 

(threaded  with  loop  suture  of  chromic  gut,  for 
aponeurosis  suture  and  muscle  sutures). 

I  needle  forceps. 

I  long,  straight,  spear-pointed  needle  (for  subcuti- 
cular suture)  (threaded  with  linen  thread  or 
silk). 

10  rubber  bolsters. 

I  one-inch  zinc  oxid  strip   (as  a  subcuticular  drain 
in  fat  patients). 
XXVI.  Laparotomy  Incision  (dressing). 

4  compresses  of  plain  gauze. 

I  packet  of  nonabsorbent  cotton. 

6  adhesive  plaster  taped  straps. 

I  binder. 


INSTRUMENTS.  I3I 

18  safety  pins. 
2  perineal  straps. 
XXVII.  Appendectomy  :  (A)  in  acute  cases,  in  addition 
to  Lists  XX  to  XXVI,  inclusive. 
2  small,  round  retractors. 

I  ligature  carrier  (armed  with  catgut  for  meso-ap- 
pendix) . 

1  small  round  needle  threaded  with  paraffin  silk  (for 

first  purse-string). 

2  small,  half -curved,  round  needles   (threaded  with 

chromic  gut  for  purse-strings  or  Lembert  suture) . 
Thermocautery  (knife  or  pointed  tip) . 
Carbolic   acid,    glass,    and   sterilized   wooden   tooth 

picks  (in  case  thermocautery  fails  to  work). 
Special  forceps  for  grasping  and  inverting  appendical 
stumps. 
(B)  Appendectomy    in    the    interval,    as    above    except 

List  XXlV. 
XXVIII.  Oophorectomy,  Salpingo-oophorectomy  (in  addi- 
tion to  Lists  XX  to  XXVI,  inclusive). 

1  ovary  forceps. 

4  Keith  clamps,   light  weight    (for  deeply  situated 
bleeding  points). 

2  medium-sized,  round  needles  (threaded  with  cat- 

gut loop  sutures  to  cover  in  raw  surfaces). 

4  strands  braided  catgut   (placed  in  pairs  on  liga- 
ture carrier). 

Thermocautery,  pointed  tip  (to  destroy  any  remain- 
ing lining  of  tube  at  uterine  end). 
XXIX.  Extrauterine  Pregnancy  (in  addition  List  XXVIII) 
Saline  infusion  (List  LXXXII). 

I  large  Chamberlain  douche  nozzle. 

I  one-gallon  pitcher. 

Saline  solution,  iio°  F.,  lo  gallons. 

4  gauze  compresses  (to  absorb  blood). 
XXX.  Hysterectomy  (in  addition  to  Lists  XX  to  XXIII, 


132  OPERATING    ROOM    AND    THE    PATIENT. 

inclusive,  that  part  of  XXIV  referring  to  vaginal 
drainage,  and  Lists  XXV  and  XXVI), 

1  eight-pronged  tenacula  forceps. 
4  braided  catgut  ligatures. 

4  Keith  clamps  (heavy). 
4  Keith  clamps  (medium). 
4  Keith  clamps  (light). 

2  medium-sized,  half-curved,  round  needles  (threaded 

with  catgut  loop  sutures  to  cover  in  raw  sur- 
faces). 

Thermocautery,    pointed   tip    (to    disinfect   cervical 
canal  in  supravaginal  amputation  of  uterus). 

Long  catgut  ligatures  (medium  size  for  deeply  situ- 
ated bleeding  points) . 

I  aneurysm  needle. 
XXXI.  Resection  of  Intestine  (in  addition  to  Lists  XX 
to  XXIII,  inclusive,  and  Lists  XXV and  XXVI). 

4  intestinal  clamps  (blades  armed  with  rubber  tub- 
ing). 

4  tapes. 

I  small,  full-bellied  scalpel. 

I  pair  straight,  sharp-pointed  scissors. 

4  half -curved,  round  needles  (threaded  with  silk  for 
guy  sutures). 

4  straight,  round  (cambric)  needles   (threaded  with 
fine  paraffin  silk). 

1  ligature  carrier. 

10  strands  of  medium-sized  catgut  for  mesentery. 

2  medium-sized,  full-curved,  round  needles  (threaded 

with  catgut  for  mesentery). 
I  set  Murphy  buttons. 
I  set  Chlumsky  buttons. 
I  set  McGraw's  elastic  ligatures  (used  only  in  very 

emergent  cases). 
Towel  wringer,  towels,  pitcher  of  hot  saline. 


INSTRUMENTS.  I33 

XXXII.  Ileocolostomy. 

Same  lists  as  for  resection  of  intestine. 

XXXIII.  Inguinal  Colostomy  (in  addition  to  Lists  XX  to 

XXIII,  inclusive,  and  Lists  XXV  and  XXVI)- 
First  stage : 

20  medium-sized,  half -curved,  round  needles  (thread- 
ed with  silk). 
Silver  wire  (for  occlusion  ligature) . 
Second  stage : 

2  pairs  mouse-tooth  forceps. 

I  pair  straight,  sharp-pointed  scissors. 

I  straight,  probe-pointed  bistoury. 

1  pus  basin. 

10  hand  sponges. 

2  paper  wool  pads. 

1  abdominal  binder. 

XXXIV.  Gastrotomy,   for  foreign  body    (in  addition  to 

Lists   XX    to    XXIII,   inclusive,    and   Lists 
XXV  and  XXVI). 

2  medium-sized,  half-curved,  round  needles  (threaded 

with  silk  for  guy  sutures). 
I  narrow-bladed  scalpel. 
I  pair  straight,  sharp-pointed  scissors.-. 
6  slender-pointed  clamps. 

1  smooth-bladed  grasping  forceps. 

2  medium-sized,  full-curved,  round  needles  (threaded 

with  loop  sutures  of  fine  chromic  gut,  for  mucous 
membrane  sutures). 
2  straight,  round  (cambric)  needles  (threaded  with 
paraffin  silk,  for  Lembert  sutures). 
XXXV.  Gastrostomy,  permanent  stomach  fistula  (in  addi- 
tion to  Lists  XX  to  XXIII,  inclusive,  and  Lists 
XXV  and  XXVI). 
15  medium-sized,  half-curved,  round  needles  (thread- 
ed with  paraffin  silk). 
I  narrow-bladed  scalpel. 


134  OPERATING    ROOM    AND    THE    PATIENT. 

1  pair  straight,  sharp-pointed  scissors. 

2  medium-sized,  half  curved,  round  needles  (threaded 

with  fine  chromic  gut  loop  sutures,  for  mucous 
membrane). 
I  soft-rubber  catheter,  No.  24  F. 
I  twelve-inch  square  of  green  silk  protective  (slit  to 
allow  tube  to  emerge). 
XXXVI.  Gastrectomy  (in  addition  to  Lists  XX  to  XXIII, 
inclusive,     and     Lists     XXV,     XXVI,     and 
XXXVII). 

1  ligature  carrier. 

18  medium-sized  catgut  ligatures  (for  omentum). 

2  medium-sized,  half -curved,  round  needles  (threaded 

with  fine  catgut  loop  sutures,  for  omentum). 

1  long-bladed  stomach  clamp  (jaws  armed  with  rub- 

ber tubing). 
6  medium-sized,  half-curved,  round  needles  (threaded 
with    fine   chromic   catgut,    for   mucous   mem- 
brane). 

2  medium-sized,  half -curved,  round  needles  (threaded 

with  paraffin  silk,  for  Lembert  sutures). 
XXXVII.  Gastroenterostomy,    posterior    (in  addition  to 
Lists  XX  to  XXIII,  inclusive,  and  Lists  XXV 
and  XXVI). 

1  blunt-pointed    anatomic    forceps    (for    separating 

mesocolon). 
12  medium-sized,  full-curved,  round  needles  (thread- 
ed with  paraffin  silk,  for  suturing  mesocolon  to 
stomach) . 

2  needle  holders  (the  nurse  arms  one  while  the  other 

is  in  use). 
2  intestinal  clamps  (jaws  armed  with  rubber  tubing). 

1  small-bladed  scalpel  (for  making  out  visceral  open- 

ings). 

2  medium-sized,  half -curved,  round  needles  (threaded 


INSTRUMENTS.  I35 

with  paraffin  silk,  eighteen-inch  lengths,  for 
continuous  Lembert  sutures). 

2  pairs  mouse-tooth  forceps  (for  steadying  intestines 
and  stomach  while  incising). 

I  pair  straight,  sharp-pointed  scissors  (for  visceral 
incisions). 

6  Kocher  clamps. 

I  medium-sized,  half -curved,  round  needle  (threaded 
with  fine  chromic  gut  loop  sutures,  for  over- 
casting cut  edge  of  intestine  and  stomach). 

1  medium-sized  Chlumsky  button  (for  lateral  intes- 

tinal anastomosis). 

2  straight,  round  (cambric)  needles  (for  closing  la- 

teral anastomosis  openings  in  intestine  up  to 
each  half  of  button). 

1  silver- wire  ligature,   medium  weight,   twelve-inch 

length  (for  occlusion  suture). 

2  slender-bladed  clamps  (for  fastening  wire). 
XXXVIII.  Cholecystostomy  (in  addition  to  Lists  XX  to 

XXIII,  inclusive,  and  Lists  XXV  and  XXVI). 

1  large,  smooth  retractor  (for  liver). 

2  medium-sized,    full-curved,    cutting-edge    needles 

(threaded  with  silk  for  guy  sutures). 

I  aspirating  syringe  and  needle.  ' 

I  narrow-bladed  scalpel. 

I  medium-sized  scoop. 

I  small  curette. 

I  pronged  grasping  forceps. 

6  medium-sized,  full-curved,  cutting-edge  needles 
(threaded  with  chromic  gut,  to  secure  drainage 
tube  to  gall-bladder). 

I  eight-inch  rubber  tube,  three-fourths-inch  diameter, 

I  medium-sized,  half -curved,  cutting-edge  needle 
(threaded  with  chromic  gut,  used  as  a  purse- 
string  for  securing  inverted  gall-bladder  to 
tube). 


136  OPERATING    ROOM    AND    THE    PATIENT. 

I  one-inch  zinc  oxid  gauze  strip  (to  pack  around 
tube). 

1  twelve-inch    square    of    rubber    dam    (to    protect 

wound  dressing). 
XXXIX.  Cholecystectomy  (in  addition   to  Lists    XX  to 
XXIII,  inclusive,  and  Lists  XXV  and  XXVI). 

2  medium-sized,    full-curved,    cutting-edge    needles 

(threaded  with  silk,  for  traction  sutures). 
I  small  scalpel  (dissecting  handle). 

1  medium-sized  scoop. 
Thermocautery,  knife  tip. 

2  braided  catgut  ligatures. 

I  one-inch  zinc  oxid  drainage  strip. 
XL.  Cholecystenterostomy  (in  addition  to  Lists  XX  to 
XXIII,  inclusive,  and  Lists  XXV  and  XXVI). 

1  small  scalpel. 

2  pairs  mouse-tooth  forceps. 

2  medium-sized,  full-curved,  round  needles  (threaded 
with  silk  for  guy  sutures). 

2  intestinal  clamps  (jaws  armed  with  rubber  tub- 
ing). 

I  pair  straight,  sharp-pointed  scissors. 

1  small  Murphy  button. 

2  medium-sized,  full-curved,  round  needles  (threaded 

with  silk,  to  close  anastomosis  openings  up  to 

each  half  of  button). 
4  medium-sized,  half -curved,  round  needles  (threaded 

with  silk  for  supporting  sutures). 
I  one-inch  zinc  oxid  gauze  drainage  strip. 
XLI.  Abdominal  Cysts    (in  addition  to  Lists  XX  to 

XXIII,  inclusive,  and  Lists  XXV  and  XXVI). 

1  large  trocar,  cannula,  tube,  and  pitcher.  "  • 

2  medium-sized,  half -curved,  round  needles  (threaded 

with  catgut  loop  sutures,   in  case  cyst-wall  is 
to  be  attached  to  the  incision). 
Thermocautery. 


INSTRUMENTS.  I37 

24  Kocher  clamps. 

6  light-weight  Keith  clamps. 

1  ligature  carrier. 

2  aneurysm  needles  (threaded  with  catgut). 
2  braided  catgut  ligatures. 

2  medium-sized,  half-curved,  round  needles  (threaded 
with  catgut  toop  sutures,  for  covering  in  raw 
surfaces). 

2  four-inch  zinc  oxid  gauze  strips. 
XLII.  Caesarian    Section    (in    addition    to     Lists     XX 
to    XXIII,    inclusive,    and    Lists    XXVI    and 
LXXXII). 

I  large,  full-bellied  scalpel. 

I  three-foot  length  of  rubber  tubing. 

12  Kocher  clamps. 

6  light-weight  Keith  clamps. 

Saline  solution,  120°  F. 

Braided  silk  for  umbilical  cord. 

Chamberlain  douche  nozzle. 

6  large,  half -curved,  round  needles   (threaded  with 
catgut,  for  uterine  sutures). 
•  12  medium-sized,  half-curved,  round  needles  (thread- 
ed with  chromic  gut  for  uterine  sutures). 

I  vulvar  pad  and  T-bandage. 

1  breast  binder. 
Fluid  extract  of  ergot. 

For  the  baby:  Tape,  hot  and  cold  baths;    olive  oil, 

toilet  powder,  and  a  warm  blanket. 

XLIII.  Ventral    and    Umbilical    Hernia    (in   addition   to 

Lists  XX  to  XXIII,  inclusive,  and  Lists  XXV 

and  XXVI ;  in  strangulated  cases  List  XXXI). 

8  medium-sized,    half -curved,    cutting-edge    needles 

(threaded  with  kangaroo  tendon  or  chromic  gut) . 

XLIV.  Inguinal    Hernia    (if    strangulated   include    List 

XXXI). 

2  large  protectors. 


138  OPERATING    ROOM    AND    THE    PATIENT. 

1  one-inch  gauze  bandage  for  penis. 
6  towels. 

2  full-bellied  scalpels  (dissecting  handles). 

1  straight,  probe-pointed  bistoury. 

2  pairs  anatomic  forceps. 
18  artery  clamps. 

2  twelve-inch  tapes  (for  retracting  cord). 

I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

I  ligature  carrier. 

4  small  retractors. 

1  medium-sized,  half-curved,  round  needle  (threaded 

with  medium-sized  catgut  for  transfixing  neck 
of  sack). 

2  needle  holders  (the  nurse  arms  one  while  the  other 

is  in  use). 

12  medium-sized,  half-curved,  round  needles 
(threaded  with  kangaroo  tendon  or  chromic  gut 
for  canal  and  aponeurotic  sutures). 

I  spatula  (for  retracting  posterior  wall  of  canal). 

I  medium-sized,  half -curved,  cutting-edge  needle 
(threaded  with  fine  catgut  loop  suture,  for  deep 
layer  of  superficial  fascia). 

I  long,  straight,  spear-pointed  needle  (threaded  with 
silk,  for  subcuticular  suture). 

12  stick  sponge  holders. 

30  hand  sponges. 

30  stick  sponges. 

I  small  hand  basin  (inverted  to  support  pelvis  while 
applying  dressing ;  the  limb  should  also  be  sup- 
ported to  relieve  strain  on  the  sutures). 

3  gauze  compresses. 

I  adhesive  plaster  strap  (placed  across  thighs  to 
support  scrotum;  to  protect  the  scrotum  a 
folded  compress  is  placed  on  the  edge  of  the 
strap) . 

I  twelve-inch  square  of  nonabsorbent  cotton. 


INSTRUMENTS.  139 

2  four-inch  muslin  bandages  (spica  of  groin). 
XLV.  Femoral  Hernia,  Fabricius  operation  (if  strangu- 
lated, include  List  XXXI). 
2  large  protectors  or  i  laparotomy  sheet. 
6  towels. 
2  full-bellied  scalpels. 

1  straight,  probe-pointed  bistoury. 

2  pairs  anatomic  forceps. 
12  artery  clamps. 

1  medium-sized,  half -curved,  round  needle  (threaded 

with  catgut,  for  transfixing  neck  of  sac). 

2  small  retractors. 

1  round  retractor  (for  retracting  femoral  vessels) . 

6  medium-sized,  full-curved,  round  needles  (threaded 
with  kangaroo  tendon  or  chromic  gut,  for  sutur- 
ing Poupart's  ligament  to  the  pectineus  mus- 
cle). 

2  needle  holders  (the  nurse  arms  one  while  the  other 

is  in  use). 
-     I  medium-sized,    half -curved,    cutting-edge    needle 

(threaded    with    fine    catgut    loop    suture,    for 

loose  cellular  tissue) . 
I  long,  straight,  spear-pointed  needle  (threaded  with 

silk  for  subcuticular  suture). 
12  stick  sponge  holders. 
30  stick  sponges. 
30  hand  sponges. 

1  small  hand  basin  (see  Inguinal  Hernia). 

3  gauze  compresses. 

4  adhesive  plaster  taped  straps. 

2  four-inch  muslin  bandages  (spica  of  groin). 
XL VI.  Vaginal  Operations  (accessories). 

I  Kelly  pad. 

I  anus  protector. 

I  pail. 

I  perineal  sheet. 


140  OPERATING    ROOM    AND    THE    PATIENT. 

Dusting  powder  to  apply  to  clitoris  after  separating 
adhesions. 
XL VII.  Curettage  (in  addition  to  List-XLVI). 

I  self -retaining     speculum,     three     interchangeable 

blades  (for  dorsal  position). 
I  large  Sims  speculum. 

1  self-retaining  and  expanding  Sims  speculum  (when 

operating  without  assistants). 

2  curved  tenacula  forceps. 

I  cervix  cleaner    (applicator  wound  with   gauze   or 

cotton) . 
I  uterine  sound. 
I  small  dilator. 
I  large  dilator. 
I  polypus  forceps. 
I  medium-sized  dull  curet. 
I  medium-sized  sharp  curet. 
I  small,  sharp  curet  (for  curetting  cornua).' 
6  stick  sponge  holders. 

I  pair  curved-on-the-fiat,  blunt-pointed  scissors. 
20  stick  sponges. 
I  uterine  dressing  forceps. 

Normal  saline  solution,  120°  F.  (in  simple  cases). 
Boro-salicylic  solution,  120°  F.  (in  suspicious  cases). 
Bichlorid  solution,  120°  F.,  1-10,000  (in  septic  cases). 
Cervix  strip  (in  septic  cases). 
I  gauze  strip  four  inches  wide  for  vaginal  pack  (in 

septic  cases  or  to  correct  displacements). 
I  paper-wool  vulvar  pad. 

1  T-bandage,  single. 
4  safety  pins. 

XL VIII.  Trachelorrhaphy  (in  addition  to  Lists  XLVI  and 
XLVII). 

2  lateral  vaginal  retractors. 

I  pair  hawksbill  scissors  scalpel. 
I  pair  tissue  forceps. 


INSTRUMENTS.  I4I 

I  pair  long-handled,  curved-on-the-flat,  sharp-point- 
ed scissors. 
30  stick  sponges. 

1  pair  anatomic  forceps  (to  hold  first  knot  of  sutures). 
10  straight  or  quarter-curved  cervix  needles  (thread- 
ed with  medium-sized  chromic  gut). 

2  needle  holders  (the  nurse  arms  one  while  the  other 

is  in  use). 
I  counterpressure  hook. 
10  artery  clamps. 

1  angle  cleaner    (similar  to  cervix  cleaner,   for  re- 

moving clots  before  tying  ligatures). 
XLIX.  Colporrhaphy,  anterior  and  posterior  (in  addition 
to  Lists  XLVI  and  XLVII). 

2  lateral  vaginal  retractors. 
I  anterior  vaginal  retractor. 

4  medium-sized,  half-curved,  round  needles  (threaded 

with  silk,  to  serve  as  retractors). 
I  scalpel. 

I  pair  tissue  forceps. 

I  pair  curved-on-the-flat,  sharp-pointed  scissors. 
6  artery  clamps. 
4   medium-sized,    half -curved,    cutting-edge   needles 

(threaded  with  chromic  gut). 

1  pair  anatomic  forceps. 
30  stick  sponges. 

L.  Colpotomy,  anterior  and  posterior  (in  addition  to 
Lists  XLVI  and  XLVII). 

2  lateral  vaginal  retractors. 

I  intraperitoneal  blade  of  self -retaining  speculum. 
I   pair  long-handled ,  curved-on-the-flat ,  blunt -pointed 
scissors. 

1  needle  holder. 

2  medium-sized,  half -curved,  round  needles  (threaded 

with  stout  silk,  to  serve  as  guy  sutures). 
6  light-weight  Keith  clamps  (for  oophorectomy). 


142  OPERATING    ROOM    AND    THE    PATIENT. 

6  braided  catgut  ligatures  (for  oophorectomy). 

2  medium-sized,  half -curved,  cutting-edge  needles 
(threaded  with  catgut  loop  sutures,  for  secur- 
ing drainage  tube  or  suturing  wound). 

Gauze  drainage  strips,  two  inches  wide  (for  cellulitis 
cases). 

Fenestrated  rubber  drainage  tubes  (three-fourths 
inch  caliber,  for  pus  cases). 

Small-sized  "horse  tracheotomy  tube"  (for  pro- 
longed drainage). 

Harrison's  rubber  drainage  tube. 

30  stick  sponges. 
LI.  Perineorrhaphy    (in   addition   to    Lists   XLIV  and 
XLVII). 

I  pair  curved-on-the-fiat,  sharp-pointed  scissors. 

I  pair  curved-on-the-fiat,  blunt-pointed  scissors. 

I  full-bellied  scalpel. 

I  pair  tissue  forceps. 

1  needle  holder. 

8  medium-sized,  half-curved,  cutting-edge  needles 
(threaded  in  pairs  with  silkworm-gut). 

2  medium-sized,   half -curved,    cutting-edge   needles 

(threaded  with  chromic  gut  loop  sutures). 

1  medium-sized,    half -curved,    cutting-edge    needle 

(threaded  with  chromic  gut,  for  skin  and  mu- 
cous membrane  suture). 
6  artery  clamps. 

2  four-inch  rubber  bolsters. 
30  stick  sponges. 

LII.  Urethral  Caruncle  (in  addition  to  Lists  XLVI  and 
XLVII). 
2  lateral  retractors. 
Thermocautery  or  electric  cautery  (fine  tip). 

1  slender-bladed  knife. 

2  pairs  mouse-tooth  forceps. 
6  slender-pointed  clamps. 


INSTRUMENTS.  143 

12  small,  half -curved,  round  needles  (threaded  with 

fine  silk). 
I  needle  holder. 
I  pair  slender,  sharp-pointed,  curved  scissors. 

1  rubber  catheter.  No.  20  F. 

12  artery  clamps  (to  use  on  sponge  sticks). 
30  small  stick  sponges. 
LIII.  Vaginal  Hysterectomy  (in  addition  to  Lists  XLVI 
andXLVII). 

2  lateral  vaginal  retractors. 
I  anterior  vaginal  retractor. 

I  intraperitoneal  blade  of  self -retaining  speculum, 

I  long-handled  scalpel. 

4  medium-sized,  full-curved,  round  needles  (threaded 
with  stout  silk,  for  traction  sutures). 

I  pair  long-handled,  curved-on-the-flat,  sharp-point- 
ed scissors. 

1  pair  long-handled,  curved-on-the-flat,  blunt-point- 

ed scissors. 
4  light-weight  Keith  clamps. 
4  medium -weight  Keith  clamps. 
4  heavy  Keith  clamps. 
4  curved  Pean  clamps. 

2  six-pronged  tenacula  forceps. 
8  Kocher  clamps. 

12  stick  sponge  holders. 

8  braided  catgut  ligatures. 

4  medium'-sized,  half -curved,  round  needles  (threaded 

with  catgut  loop  sutures,  for   covering  in  raw 

surfaces  and  suturing  incision). 
2  zinc  oxid  gauze  strips  eight  inches  wide. 
LIV.  Fistula,  vesicovaginal,  rectovaginal  (in  addition  to 

Lists  XLVI,  XLVII  and  XLIX). 
2  paring  knives. 
4  small  half-curved   round    needles   threaded    with 

silk. 


144  OPERATING    ROOM    AND    THE    PATIENT. 

LV.  Circumcision. 

I  laparotomy  sheet  or  2  large  protectors. 
6  towels. 

I  strong,  flat-ended,  silver  probe  (to  break  up  adhe- 
sions) . 
3  artery  clamps. 
.     I  circumcision  clamp  (in  adults). 

1  pair  curved-on-the-flat,  sharp-pointed  scissors. 

2  pairs  mouse-tooth  forceps. 
I  pair  anatomic  forceps. 

6  small,  half -curved,  cutting-edge  needles  (threaded 
with  fine  catgut). 

3  six-inch   squares   of  lint  with   slit   in   center  just 

large   enough  to   allow   of   glans   being   forced 
through  (to  hold  back  foreskin). 

■2"  ounce  of  melted  zinc  oxid  ointment  (not  hot 
enough  to  burn ;  to  pour  between  layers  of  lint ; 
this  hardens  and  keeps  the  dressing  from  slip- 
ping). 

I  square  of  oiled  silk  protective  slit  in  center  (to 
protect  dressing). 

I  three-inch  gauze  bandage  (double  spica  of  groin). 

12  hand  sponges. 
LVI.  Varicocele. 

I  laparotomy  sheet  or  2  protectors. 

6  towels. 

1  one-inch  gauze  bandage   (wet  with  bichlorid,   for 

penis). 

2  scalpels. 

2  pairs  anatomic  forceps. 

6  artery  clamps. 

2  aneurysm    needles    (threaded    with    medium-size 

catgut  for  ligating  veins). 
I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  pair  blunt  hook  retractors, 

2  pieces  of  tape. 


INSTRUMENTS.  I45 

I  medium-sized,  half -curved,  cutting-edge  needle 
(threaded  with  fine  catgut  loop  suture,  for  sew- 
ing vein-stumps  together). 

I  medium-sized,  curved,  cutting-edge  needle  (thread- 
ed with  medium  sized  chromic  gut,  for  sutur- 
ing skin  incision). 

I  medium-sized,  curved,  cutting-edge  needle  (thread- 
ed with  fine  catgut,  in  case  tunica  is  opened). 

12  hand  sponges. 

I  strip  of  adhesive  plaster  eighteen  inches  by  four 
inches,  placed  across  thighs  to  support  scrotum). 

I  gauze  compress,  folded  (to  protect  scrotum  from 
edge  of  adhesive  plaster  support). 

3  gauze  compresses. 

I  small  hand  basin  (pelvic  support). 

1  twelve -inch  square  of  nonabsorbent  cotton. 

2  three-inch  gauze  bandages  (single  spica  of  groin). 
LVII.  Hydrocele,  open  operation. 

I  laparotomy  sheet  or  2  protectors. 
6  towels. 
"     I  curved,  sharp-pointed  bistoury. 
I  scalpel. 
12  artery  clamps. 

1  pair  curved-on-the-flat,  blunt -pointed  scissors. 

2  pairs  mouse-tooth  forceps. 

I  pair  small,  blunt  hook  retractors. 

12  hand  sponges. 

I  zinc  oxid  gauze  drainage  strip,  two  inches  wide. 

6   medium-sized,   half -curved,   cutting-edge   needles 

(threaded  with  silk  or  chromic  gut). 
I  adhesive  plaster  strip  for  scrotum  (see  Varicocele) . 
I  gauze  compress,  folded  (see  Varicocele). 

3  gauze  compresses. 

I  twelve-inch  square  of  nonabsorbent  cotton. 
I  four-inch  gauze  bandage. 
LVm.  Hypospadias  (methods  of  Anger  and  Duplay). 


146  OPERATING    ROOM    AND    THE    PATIENT. 

1  laparotomy  sheet  or  2  large  protectors. 

2  small,  flat -bellied  scalpels. 
6  towels. 

2  pairs  small,  mouse-tooth  forceps. 
I  pair  slender,  anatomic  forceps. 

6  slender-pointed  artery  clamps. 

I  pair  small,  curved-on-the-flat,  sharp-pointed  scis- 
sors. 

12   small,   half -curved,   round  needles    (threaded  in 
pairs  with  fine  silk). 

6  small,  half -curved,  round  needles  (threaded  with 
fine  silk). 

6  small,  half-curved,  round  needles   (threaded  with 
fine  catgut). 

I  soft -rubber  catheter.  No.  14  F. 

I  gauze  compress,   shaken  out   (held  in  place  with 
safety  pin). 
LIX.  Internal  Urethrotomy. 

I  laparotomy  sheet  or  2  large  protectors. 

6  towels. 

4  ounces  of  olive  oil  in  a  glass. 

I  glass  piston  syringe. 

3  dozen  filiform  bougies. 
I  set  tunneled  sounds. 

I  urethrotome. 
I  complete  set  of  sounds. 
I  soft -rubber  catheter.  No.  20  F. 
Boro-salicylic  irrigation  and  glass  connection  to  fit 
catheter  (to  flush  out  urethra). 

4  well-padded   pieces   of  bass-wood   four  inches  by 

one-half  inch,  to  splint  penis  in  case  of  severe 
hemorrhage. 
I  one-inch  gauze  bandage  and  safety  pin  to  secure 
splint. 
LX.  Perineal  Section,  for  stricture  and  drainage,  in  addi- 
tion to  List  LIX. 


INSTRUMENTS.  I47 

I  perineal  sheet. 

3  towels. 

Trocar  and  cannula. 

I  set  lithotomy  staffs. 

I  full-bellied  scalpel. 

I  long,  grooved  director. 

I  straight,  probe-pointed  bistoury. 

I  perineal  director. 

1  gorget. 

2  blunt  hook  retractors  (when  dissection  of  urethra 

is  necessary). 
6  artery  clamps. 
I  large  examining  cystoscope. 

I  slender  forceps  (to  aid  in  passing  perineal  tube). 
I  soft -rubber  peritoneal  tube,  No.  36  F. 
I  large,  curved,  cutting-edge  needle  (threaded  with 

stout  silk  to  secure  tube). 

3  medium-sized,    full-curved,    cutting-edge    needles 

(threaded  with  silk). 

20  hand  sponges. 

30  stick  sponges. 

12  stick  sponge  holders. 

Saline  irrigation  and  glass  connection  to  fit  perineal 
tube. 

I  umbrella  tampon  (in  case  of  severe  bleeding). 
This  is  made  by  passing  the  perineal  tube 
through  the  center  of  an  eight-inch  square 
double  thickness  of  gauze.  The  gauze  near  tV.e 
aperture  in  it  is  sewn  fast  to  the  tube  at  a 
point  which,  when  the  tube  is  in  position,  lies 
just  within  the  bladder.  The  tube  is  inserted 
and  the  interior  of  the  umbrella  tightly  packed 
with  small  strips  of  gauze  the  ends  of  which 
emerge  alongside  of  the  tube. 

3  gauze  compresses  (with  apertures  cut  to  allow 
passage  of  tube). 


148  OPERATING   ROOM    AND    THE    PATIENT. 

I  T-bandage,  double.    • 

1  glass  connection  (to  attach  perineal  tube  to  rubber 

tube  leading  to  urine  bottle). 
LXI.  In   Impassable  Stricture   Cases  :    Perineal  Section 
Without  a  Guide  (in  addition  to  List  LX). 

2  pairs  mouse-tooth  forceps. 

6  small,  half -curved,  round  needles  (threaded  with 
silk,  to  aid  in  retraction  and  to  identify  re- 
mains of  urethra). 

I  needle  holder. 

I  pair  curved-on-the-flat,  sharp-pointed  scissors. 

1  long,  silver  probe. 

2  single  tenaculse. 

LXII.  In  Stone  Cases  (in  addition  to  List  LX). 
I  Thompson  searcher. 

I  set  of  stone-crushing  and  stone-grasping  forceps. 
LXIII.  Prostatectomy,  perineal  (in  addition  to  List  LX). 
I  urethral  divulsor. 

1  rubber  retractor  and  piston  syringe  (Parker  Syms). 

2  prostatic  retractors. 

2  three-prong,  blunt-pointed  volvellum  forceps. 
LXIV.  Suprapubic  Cystotomy. 

1  laparotomy  sheet  or  2  large  protectors. 
6  towels. 

2  scalpels. 

2  blunt  hook  retractors. 

1  pair  curved-on-the-fiat,  sharp-pointed  scissors. 

2  narrow-bladed  retractors. 

4  small,   full-curved,  round  needles   (threaded  with 

silk  for  guy  sutures). 
I  needle  holder. 

I  electric  light  bladder  retractor. 
I  electrocautery  set,  for  removing  portions  of  tumors. 
I  set  of  stone  instruments  (List  LXII). 
4  small,  full-curved,   round  needles   (threaded  with 

chromic  gut,  for  suturing  bladder). 


INSTRUMENTS.  I49 

I  soft -rubber  suprapubic  drainage  tube,  No.  40  F., 
with  glass  connection  to  fit.  (This  is  attached 
by  a  rubber  tube  to  a  Dawbarn  apparatus  at 
the  bedside.) 

1  three-inch  zinc  oxid  gauze  packing  strip. 

2  narrow  strips  of  adhesive  plaster  (to  retain  tube 

in  position). 
2  gauze  compresses. 
I  twelve-inch  square  of  nonabsorbent  cotton. 

1  abdominal  binder  (split  to  allow  passage  of  tube). 

2  perineal  straps. 
18  safety  pins. 

LXV.  Kidney  Incision  (for  exposing  kidney). 

1  oblong  sand  pillow  eighteen  inches  long,   twelve 

inches   wide,    and   eight   inches   thick,    covered 
with  sterile  towel. 

2  large  protectors. 

2  full-bellied  scalpels. 

2  pairs  anatomic  forceps. 

6  artery  clamps. 

2  pairs  curved-on-the-fiat,  blunt-pointed  scissors. 

2  medium-sized  retractors,  one  with  six-inch  blade  and 

one  with  four -inch  blade  (for  deep  retracting). 
50  hand  sponges. 
30  stick  sponges. 
12  stick  sponge  holders. 
LXVI.  Kidney  Incision  (closing). 

12    full-curved,    cutting-edge   needles    (threaded   in 

pairs  with  silkworm-gut). 
I  long,  straight,  spear-pointed  needle  (threaded  with 

silk  for  subcuticular  suture). 
I  gauze  strip  four  inches  wide  by  three  yards  long  (if 

kidney  support  is  needed). 

3  gauze  compresses. 

3  folded  towels  (to  serve  as  anterior  support  for  kid- 
ney). 


150  OPERATING    ROOM    AND    THE    PATIENT. 

4  taped  adhesive-plaster  straps. 

I  twelve -inch  square  of  nonabsorbent  cotton. 

1  abdominal  binder. 

LXVII.  Kidney  Exploration  (in  addition  to  Lists  LXVI 
and  LXVII). 

2  long,  blunt-pointed,  steel  pins  (hat  pins  with  ends 

blunted) . 
I  exploring  syringe  and  needle. 
Thermocautery  knife  (pointed  tip). 
I  flat-bellied  knife  with  dissecting  handle  (for  split- 
ting or  removing  capsule). 
I  large,  flat-bellied,  broad-bladed  knife  for  splitting 

kidney. 
I  special  forcep  for  compressing  pedicle  (jaws  armed 

with  rubber  tubing). 
I  needle  holder. 
6  long,   straight,   round  needles    (threaded  in  pairs 

with  paraffined   silk  eighteen-inch  lengths,   for 

through-and-through  sutures). 
6  medium-sized,  full-curved,  round  needles  (threaded 

with  paraffin  silk  for  hemostatic  sutures). 

1  urethral  probe  (hollow). 

2  long,  silver  probes. 

LXVIII.  Nephrotomy  (in  addition  to  Lists  LXV,  LXVI, 
and  LXVII). 

3  Keith  clamps. 

2  large,  dull  curettes. 

Saline  irrigation. 

Peroxid  and  sodium  bicarbonate  solution. 

1  pair  dressing  forceps. 

2  fenestrated  rubber  drainage  tubes. 

3  zinc  oxid  gauze  packing  strips. 

LXIX.  Kidney  Suspension  (in  addition  to  Lists  LXV  and 
LXVI). 
6  artery  clamps  (for  traction  on  the  fatty  capsule), 

4  medium-sized,  half -curved,  round  needles  (threaded 


INSTRUMENTS.  151 

with  silk,  eighteen-inch  lengths,  for  suspension 
sutures  in  pairs). 
4  medium-sized,  full-curved,  round  needles  ("threaded 
with  kangaroo  tendon.     For  suspension  by  band 
from  quadratus  lumborum). 
LXX.  Nephrectomy  (in  addition  to  Lists  LXVand  LXVI). 

2  long,  curved,  Pean  clamps. 

3  Keith  clamps. 

2  braided  catgut  ligatures. 
I  ligature  carrier. 

I  pair  long,   curved-on-the-flat,   blunt-pointed   scis- 
sors. 

OPERATIONS  UPON  THE  RECTUM  AND  ANUS. 

LXXI.  Fistula  in  Ano. 

1  perineal  sheet. 
6  towels. 

2  silver  probes. 

I  wire  rectal  speculum. 

I  long,  grooved  director. 

I  scalpel. 

I  curved,  sharp  pointed  bistoury. 

1  curved,  blunt-pointed  bistoury. 

2  mouse-tooth  forceps. 

I  pair  curved-on-the-fiat,  blunt -pointed  scissors. 

1  medium-sized  sharp  curette. 

2  blunt  hook  retractors. 
Hydrogen  peroxid. 

I  large  glass  syringe. 

1 2  artery  clamps. 

I    medium-sized,    half -curved,    cutting-edge    needle 

(threaded  with  catgut  for  circumsuture  in  case 

of  troublesome  hemorrhage). 
I  large  umbrella  tampon  (see  List  LX). 
6  stick  sponge  holders. 
30  stick  sponges. 


152  OPERATING    ROOM    AND    THE    PATIENT. 

I  2 -grain  opium  suppository. 

I  I -grain  iodoform  suppository. 

Vaselin  for  anointing  suppositories. 

I  three-inch  strip  of  balsarn-of-Peru  gauze. 

I  paper-wool  pad. 

I  T-bandage. 
LXXII.  Hemorrhoids  (combined  Hgature  and  cautery  op- 
eration) . 

I  perineal  sheet. 

6  towels. 

I  rectal  speculum. 

6  large  hemorrhoid  clamps  (ring  clamps). 

6  small  hemorrhoid  clamps  (ring  clamps). 

I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

6  large,  half -curved,  cutting-edge  needles  (threaded 
with  eighteen-inch  lengths  of  catgut  for  trans- 
fixing hemorrhoids). 

6  artery  clamps. 

I  Thermocautery  (button  or  knife  tip). 

6  medium-sized,  half -curved,  cutting-edge  needles 
(threaded  with  catgut  for  use  as  a  purse-string 
in  covering  in  raw  surfaces). 

I  2 -grain  opium  suppository. 

I  i-grain  iodoform  suppository. 

Vaselin  for  anointing  suppositories. 

I  Kelsey  hemorrhoid  clamp  (in  simple  cautery  oper- 
ations). 

30  stick  sponges. 

6  stick  sponge  holders. 

I  large  umbrella  tampon. 

I  paper-wool  pad. 

1  T-bandage,  double. 

LXXIII.  Prolapsus  Recti,  suspension  of  rectum. 

2  large  protectors. 
6  towels. 

2  scalpels. 


INSTRUMENTS.  153 

2  pairs  anatomic  forceps. 
12  Kocher  clamps. 

I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

3  blunt  hook  retractors. 
I  pair  tissue  forceps. 

I  needle  holder. 

I  large,  curved,  cutting-edge  needle  (threaded  with 
chromic  gut  or  kangaroo  tendon  for  circum- 
suture  of  rectum). 
6  medium-sized,  half -curved,  cutting-edge  needles 
(threaded  with  chromic  gut  or  kangaroo  ten- 
don, for  suspension  sutures  of  rectum) . 
12     medium-sized,     half -curved,     cutting     needles 

(threaded  with  silkworm-gut). 
3  gauze  compresses. 
I  T-bandage. 
LXXIV.  Extirpation  of  Rectum  by  the  Abdomino-perineal 
Route  (in  addition  to   Lists  XX  to  XXIII, 
inclusive,  and  Lists  XXV  and  XXVI). 

1  ligature  carrier. 

2  heavy  silk  ligatures  (for  sigmoid) . 

1  pair  straight,  sharp-pointed  scissors. 

lo  eigtheen-inch  lengths  of  catgut  (for  mesorectum). 

2  aneurysm  needles,  right  and  left   (threaded  with 

catgut,  for  ligating  internal  iliac  arteries). 
I  six-inch  iodoform  gauze  strip  (to  wrap  around  ends 

of  sigmoid). 
12  medium-sized,     half -curved,     round     needles 

(threaded  with  silk,  for  artificial  anus). 

1  perineal  sheet. 

2  heavy  Keith  clamps. 
12  light  Keith  clamps. 

1  six-inch  zinc  oxid  gauze  strip. 

2  paper-wool  pads. 
Collodion,  brush,  and  glass. 
6  gauze  compresses. 


154  OPERATING    ROOM    AND    THE    PATIENT. 

I  T-bandage. 
LXXV.  Resection  of  Joints. 

1  large  sheet. 

2  small  protectors. 
6  towels. 

Hand  or  foot  bags. 
I  rubber  bandage. 

1  Esmarch  constrictor. 

2  scalpels. 

1  resection  knife. 

2  pairs  anatomic  forceps. 
24  artery  clamps. 

I  pair  curved -on-the-fiat,  blunt -pointed  scissors. 

1  periosteal  elevator. 

3  blunt  hook  retractors. 

2  sharp  hook  retractors. 
2  Gigli  saws. 

I  chain  saw  and  carrier. 
I  butcher  saw. 
I  metacarpal  saw. 
I  bone-cutting  forceps. 

1  rongeur  forceps. 

2  sharp  Volkmann  spoons. 

1  lion-jaw  forceps. 

2  medium-sized,    half -curved,    cutting-edge    needles 

(threaded  with  loop  sutures  of  catgut). 
10  medium-sized,  half -curved,  cutting-edge    needles 

(threaded  with  silkworm-gut). 
6  stick  sponge  holders. 
50  stick  sponges. 
30  hand  sponges. 

I  three-inch  zinc  oxid  gauze  strip. 
6  gauze  compresses. 

3  packets  of  nonabsorbent  cotton. 
3  muslin  bandages. 

Splints  (Richardson's  in  shoulder  cases,  right-angled 


INSTRUMENTS.  155 

in  elbow  cases,  bass-wood  in  wrist  cases,  Volk- 
mann  in  knee  and  ankle  cases). 
Plaster-of-Paris  bandages,   salt  solution,   and  addi- 
tional plaster. 
LXXVI.  Amputation. 

1  large  sheet. 

2  small  protectors. 
Foot  or  hand  bags. 
6  towels. 

I  rubber  bandage. 

1  Esmarch  constrictor. 

Wyeth's  pins,  corks,  and  three-foot  length  of  rub- 
ber tubing  in  hip  and  shoulder  cases) . 

2  scalpels. 

2  pairs  anatomic  forceps. 

24  Kocher  clamps. 

2  blunt -nosed  clamps  (for  artery  and  vein) . 

I  large  amputating  knife. 

I  Catlin  knife  (for  leg  and  forearm). 

I  pair  curved-on-the-flat,  blunt -pointed  scissors. 

1  periosteal  elevator. 

2  Gigli  saws. 
I  chain  saw. 

I  butcher  saw. 

I  mallet  and  chisel. 

I  bone-cutting  forceps. 

I  rongeur  forceps. 

I  bone-grasping  forceps. 

3  blunt  hook  retractors. 

1  bandage  retractor  (two-tailed  for  arm  and  thigh, 

three-tailed  for  forearm  and  leg). 

2  medium-sized,    half -curved,    cutting-edge    needles 

(threaded  with  catgut  loop  sutures). 
10  medium-sized,  half -curved,  cutting-edge  needles 

(threaded  with  silkworm-gut). 
30  hand  sponges. 


156  OPERATING    ROOM    AND    THE    PATIENT. 

I  four-inch  zinc  oxid  gauze  strip. 
6  gauze  compresses. 

1  six-yard  gauze  roll. 

2  adhesive  plasters,  taped  straps. 

1  four-inch  gauze  bandage. 
Bass-wood  splints. 

2  three-inch  muslin  bandages. 
LXXVII.  Suturing  of  the  Patella. 

2  large  protectors. 

1  foot  and  leg  bag, 
6  towels. 

2  scalpels. 

2  pairs  anatomic  forceps. 
12  Kocher  clamps. 

1  pair  curved-on-the-flat,  blunt -pointed  scissors. 

2  blunt  hook  retractors. 
2  sharp  hook  retractors. 

I  sharp  Volkmann  spoon. 

1  bone  drill  (silkworm-gut  for  carrier). 

4   medium-sized,    full-curved,    cutting-edge   needles 

(threaded   with   kangaroo   tendon    or   chromic 

gut,  for  lateral  sutures). 
4  medium-sized,   half -curved,   cutting-edge   needles 

(threaded    with   kangaroo   tendon    or   chromic 

gut,  for  capsule  sutures). 

2  strands  of  kangaroo  tendon,  chromic  gut,  or  silver 

wire  (for  through-and -through  suture). 
I  long,  straight,  spear-pointed  needle  (threaded  with 
silk  for  subcuticular). 

1  Volkmann  splint. 

2  gauze  compresses. 

1  six-yard  gauze  roll. 

3  packets  of  nonabsorbent  cotton. 

2  three-inch  muslin  bandages  (for  foot  and  leg). 
I  four-inch  muslin  bandage  (for  thigh). 


INSTRUMENTS.  157 

LXXVIII.  Varicose  Veins  (method  of  Trendelenburg). 
2  large  protectors. 
6  towels. 
2  scalpels. 

2  pairs  anatomic  forceps. 
6  Kocher  clamps. 
2  blunt  hook  retractors. 
I  aneurysm  needle    (threaded  with  two  strands  of 

catgut) . 
I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

1  long,  straight,  spear-pointed  needle  (threaded  with 

silk,  for  subcuticular  suture). 
6  hand  sponges. 

2  gauze  compresses. 

2  adhesive  plaster  taped  straps, 
2  two-inch  muslin  bandages  (for  foot  and  leg). 
2  three-inch  muslin  bandages  (for  thigh  and  pelvis) . 
LXXIX.  Abscess. 
2  large  protectors. 
6  towels. 

I  exploring  syringe  and  large  needle. 
I  scalpel. 

I  narrow-bladed  artery  clamp. 
6  Kocher  clamps. 

1  grooved  director. 

2  pairs  anatomic  forceps. 
2  blunt  hook  retractors. 

1  pair  curved-on-the-flat,  blunt-pointed  scissors, 

2  sharp  Volkmann  spoons. 

6   medium-sized,    half-curved,    cutting-edge   needles 

(threaded  with  silkworm-gut) , 
Peroxid  of  hydrogen. 
I  large  glass  syringe. 
Boro-salicylic  irrigation, 
6  stick  sponge  holders. 
30  stick  sponges. 


158  OPERATING    ROOM    AND    THE    PATIENT. 

30  hand  sponges. 

Carbolic  acid  (in  tubercular  cases). 
Alcohol  (in  tubercular  cases). 

Peroxided    zinc    gauze    strips    (oxid    of   zinc    gauze 
strips  wrung  out  of  peroxid  of  hydrogen). 

2  fenestrated  rubber  drainage  tubes. 
6  compresses. 

3  three-inch  gauze  bandages. 

In  Bone  Cases  (in  addition  to  above). 
I  periosteal  elevator. 
I  sequestrum  forceps. 
I  rongeur  forceps. 
3  bone  gouges. 

3  chisels. 

1  mallet. 

Mixture  of  whale  oil  and  iodoform  (for  filling  bone 
cavities) . 
LXXX.  Skin-grafting. 

2  large  protectors. 
6  towels. 

I  skin-grafting  razor. 

1  pair  sharp  hook  retractors  (to  steady  skin). 

2  pairs  anatomic  forceps. 

2  flat-ended,  silver  probes. 

Basin  of  saline,  105°  F. 

Green  silk  protective  (cut  in  one-inch  strips). 

6  hand  sponges. 

4  compresses  (wet  with  saline). 
2  three-inch  gauze  bandages. 

For  Surface  to  be  Grafted  (in  addition  to  above). 

I  pair  curved-on-the-flat,  blunt-pointed  scissors. 

I  pair  straight,  sharp-pointed  scissors. 

I  sharp-pointed  Volkmann  spoon. 
LXXXI.  Plaster-of-Paris  Outfit  (application  of  cast). 

Vaselin. 

Nonabsorbent  or  French  cotton  rolls. 


INSTRUMENTS.  1 59 

Canton  flannel  bandages. 

Plaster  bandages. 

Additional  plaster. 

Salt  solution  in  basin  (deep  enough  to  allow  immer- 
sion of  bandages). 

Sand -bags. 

Vinegar  (for  removing  plaster  from  the  hands). 

Adhesive  plaster  and  sharp  plaster  knife  (if  cast  is 
to  be  fenestrated  or  cut  down  at  once  to  facili- 
tate rapid  removal). 

Soft-iron  strips  and  bass-wood  splints  (for  strengthen- 
ing casts). 
Removal  of  Cast. 

Small  circular  saw. 

Heavy  plaster  shears. 

Heavy  plaster  knife. 

Vinegar  or  strong  bichlorid  solution  (to  soften  plas- 
ter). 
LXXXII.  Intravenous  Infusion. 

6  towels. 

I  muslin  bandage  (for  constriction). 

1  scalpel. 

2  pairs  anatomic  forceps. 

1  aneurysm  needle  (threaded  with  silk). 

2  Kocher  clamps. 

I  pair  curved-on-the-fiat,  blunt -pointed  scissors. 
I  pair  slender,  curved-on-the-flat,  sharp-pointed  scis- 
sors. 
Infusion  cannula  and  connecting  tubing  with  cut  off. 
Glass  infusion  jars  and  thermometer. 
Stand  for  infusion  apparatus. 
Saline  solution,  120°  F.,  1200  c.c. 

1  medium-sized,     half-curved,     cutting-edge    needle 

(threaded  with  silk). 

2  hand  sponges. 

I  gauze  compress. 

I  three-inch  gauze  bandage. 


INDEX 


Abdomen,  preparation  of,  80 
upper,   position  for  operations 
upon,  86 
Abdominal  bandage,  44 
binder,  45 

in  dorsal  position,  100 
cysts,  instruments  for,  136 
drainage,  instruments  for,   129 
dressing  in  dorsal  position,  100 
operations,  instruments  for,  128 
Abscess,    bone,    instruments    for, 
158 
instruments  for,  157 
Accessories,  extra-abdominal,  128 
intra-abdominal,  129- 
vaginal,  139 
Acid  bichlorid,  32 
boric,  3 1 

gauze  of,  38 
solutions  of,  T,^ 
carbolic,  solutions  of,  33 
oxalic,  crystals  of,  31 

solution  of,  34 
salicylic,  32 
Adenectomy,       cervical,      instru- 
ments for,  125 
Adenoids,  instruments  for,   124 
Adhesive  plaster,  45 
After-treatment,   albuminuria  in, 

113 
anuria  in,  114 
autointoxication  in,  116 
bed  in,  103 
cystitis  in,  114 
digestion  in,  1 1 1 
dilatation  of  stomach  in,  112 
fecal  impaction  in,  112 


After-treatment,   general   appear- 
ance of  patient,  107 
considerations,  102 
rules  of  hygiene  in,   113 
nutrition  in,  no 
pain  in,  109 
parotitis  in,  108 
position  of  patient  in,  104 
preparation  of  bed  in,  103 
pulse  in,  117 
purpose  of,  102 
respiration  in,  117 
retention  of  urine  in,  114 
temperature  in,  115 
thirst  in,  109 
urine  in,  113 
Albuminuria,   postoperative,    113 
Alcohol,  35 
Ammonia  solution,  34 
Amputation,  breast,  instruments 
for,  127 
position  for,  84,  86 
instruments  for,  155 
Analgesia,  spinal,  59,  70 

rules  for  making  injection,  71 
Anesthesia,  54 
anesthol,  68 
chloroform,  63 
cocain,  73 

of  skin,  74 
ether,  59 

circulatory  failure  in,  63 
cyanosis  in,  61 
ethyl  bromid,  65 
nitrous  oxid,  58 
and  ether,  66 
and  oxygen,  66 


161 


l62 


INDEX. 


Anesthesia,  preparation  just  pre- 
vious to,  83 
recovery  from,  105 
Anesthetic  nurse,  21 
room,  54 

furniture,  54 
selection  of,  58 
vomiting,  105 

character  of  vomit,  106 
persistent,  106 
treatment  of,  106 
Anesthetist,  costume  of,  16 

duties  of,  57 
Anesthol  anesthesia,  68 
Antiseptic  catgut  No.  r,  steriHza- 
tion  of,  50 
No.  2,  steriHzation  of,  50 
No.  3,  steriHzation  of,  50 
Anuria,  facial  expression  in,  108 

postoperative,  114 
Anus,  fistula  of,  instruments  for, 

151 
operations  on,  instruments  for, 

151 
preparation  of,  80 
protectors,  30 

sterilization  of,  30 
Appendectomy,    instruments   for, 

131 
Aprons,  rubber,  27 
Aseptic  fever,  116 
causes  of,  116 
Assistant's  costume,  16 
Autointoxication,    postoperative, 

116 
Axilla,  preparation  of,  80 


Bainbridge's  method  of  making 

fresh   cocain   solutions,    75 
Balsam  of  Peru,  35 

gauze,  39 
Bandage  box,  44 
Bandages,  43 

abdominal,  44 

chest,  44 

crinolin,  44 


Bandages,  dimensions  of,  43 

double  roller  head,  44 

finger,  44 

flannel,  44 

gauze,  43 

muslin,  43 

plaster,  44 

retractor,  44 

rubber,  47 

starch,  44 

T-,  44 

double,  45 

triangular,  45 
Basins,  glass,   disinfection  of,    15 

hand,  disinfection  of,  14 

pus,  disinfection  of,  14 
Bed  in  after-treatment,  103 

length  of  stay  in,  105 
Bed-rest,  104 
Benzin,  34 

Bicarbonate  of  soda,  32 
Bichlorid  acid,  32 

of  mercury,  32 
gauze,  38 
Bichlorid-permanganate  solution, 

33 

Bichromate  of  potash,  3  2 
solution,  34 

Binder,  abdominal,  45 

in  dorsal  position,  100 
breast,  45 

Blankets,  30 

sterilization  of,  30 

Blood,  examination  of,  76 

Bolsters,  rubber,  47 

Bone,  abscess  of,  instruments  for, 
158 

Boric  acid,  31 
gauze,  38 
solutions,  ^^ 

Boro-salicylic  solution,  ^;i 

Bougies,  filiform,  47 

Bowels,  preparation  of,  78 

Braided  catgut,  sterilization  of ,  51 

Brass  work,  cleansing  of,  15 

Breast,    amputation    of,    instru- 
ments for,  127 


INDEX. 


163 


Breast,    amputation    of,    position 
for,  84,  86 

binder,  45 
Brushes,  25 

sterilization  of,  25 


C^SARiAN     section,     instruments 
for,  137 

Cannula,  Trendelenburg,  68 

Caps,  27 
nurses',  27 
patients',  27 
surgeons',  27 

Carbolic  acid  solutions,  t,^ 

Carbolized  gauze,  39 

Carbonate  of  soda,  32 

Carotids,     occlusion     of,     instru- 
ments for,  126 

Caruncle,     urethral,    instruments 
for,  142 

Cast,  plaster-of-Paris,  instruments 
for  removal  of,  159 

Catgut,    antiseptic    No.    i,   steril- 
ization of,  50 
No.  2,  sterilization  of,   50 
No.  3,  sterilization  of,  50 
braided,  sterilization  of,  5 1 
chromic  No.  i,  sterilization  of, 

49 
No.  2,  sterilization  of,  50 
formalin,  sterilization  of,  50 
iodin,  sterilization  of,  5 1 
sterilization  of,  48 
Catheterization  in  female,  114 
Cervical  adenectomy,  instruments 

for,  125 
Chest  bandage,  44 
Chlorid  of  zinc  solution,    34 
Chlorinated  lime,  27 
Chloroform  anesthesia,  63 
Cholecystectomy,  instruments  for, 

136 
Cholecystenterostomy,      instru- 
ments for,  136 
Cholecystostomy,  instruments  for, 
135 


Chromic    catgut    No.  i,    steriliza- 
tion of,  49 
No.  2,  sterilization  of,  50 

Cigarette  drains,  40 

Circulatory  failure  in  ether  anes- 
thesia, 63 

Circumcision,      instruments     for, 
144 

Cocain  anesthesia,  73 
of  skin,  74 
hydrochlorate,  32 
solutions,  35 

Colostomy,  inguinal,  instruments 
for,  133 

Colporrhaphy,     instruments     for, 

141 

Colpotomy,  instruments  for,   141 

Compresses,  43 

Condenser,  Dowd's  49 

Cotton,  absorbent,  41 
sterilization  of,  41 
nonabsorbent,  41 
sterilization  of,  41 

Covers  for  rubber  pads,  3 1 

Craniectomy,  instruments  for,  120 

Crinolin  bandages,  44 

Curettage  of  uterus,  instruments 
for,  140 

Cut  throat,  instruments  for,   126 

Cyanosis  in  ether  anesthesia,  61 

Cystitis,  postoperative,  114 

Cystotomy,     suprapubic,     instru- 
ments for,  148 

Cysts,     abdominal,     instruments 
for,  136 


Dam,  rubber,  sterilization  of,  47 
Dependent  head  position,  83,  85 
Deviated      septum,    instruments 

for,  124 
Diet,  78 

Digestion  in  after-treatment,  in 
Dilatation  of  stomach,  postopera- 
tive, 112 
Disinfection  of  dressing  pails,   14 
of  enamelware,  14 


164 


INDEX. 


Disinfection  of  glass  basins,  15 
of  hand  basins,  14 
of  operating  room,  14 
of  pitchers,  14 
of  pus  basins,  14 
of  tables,  15 
Distention,    facial   expression   in, 

107 
Dorsal  position,  87 

abdominal  binder  applied,  100 

dressing  applied,  100 
arms  fastened  ready  for  final 

preparation,  95 
operation  suit,  82 
ready  for  operation,   97 
Dowd's  condenser,  49 
Drain,  cigarette,  40 
gauze,  39 
Mikulicz,  41 
rubber  tissue,   41 
wi eking,  39 
Drainage,  abdominal,  instruments 
for  129 
tubes,  rubber,  47 

sterilization  of,  74 
Dressing,    abdominal,     in     dorsal 
position,  100 
application  of,  100 
laparotomy     incision,     articles 

for,  130 
pails,  disinfection  of,  14 


Empyema,  instruments  for,  127 

Enamelware,  disinfection  of,  14 

Ergotol  solution,  55 

Esophagus,  preparation    of,  81 

Ether  anesthesia,   59 

circulatory  failure  in,  63 
cyanosis  in,  61 
commercial,  35 
inhaler,  preparation  of,  56 

Ethyl  bromid  anesthesia,  65 

Exaggerated  lithotomy  position, 
90,  92 

Excision     of     trigeminus,  instru- 
ments for,  120 


Excision  of  upper  jaw,  instru- 
raents  for,  120 

Exploration,  kidney,  instruments 
for,  150 

Extended  neck  position,  83,  85 

Extirpation  of  rectum  by  ab- 
domino-periileal  route,  instru- 
ments for,  153 

Extra-abdominal  accessories,   128 

Extrauterine  pregnancy,  instru- 
ments for,  131 

Extremities,  preparation  of,  81 

Facial  expression  in  anuria,   108 

in  distention,  107 

in  hemorrhage,  107 

in  peritonitis,  107 

in  pneumonia,  108 

in  uncomplicated   cases,    107 
Fecal    impaction    in    after-treat- 
ment, 112 
Female,  catheterization  in,  114 
Femoral  hernia,  instruments  for, 

139 
Files,  nail,  26 
Filiform  bougies,  47 
Finger  bandage,  44 

cots,  29 
Fistula  in  ano,   instruments   for, 

151 

rectovaginal,    instruments    for, 

143 
vesicovaginal,  instruments  for, 

143 
Flannel  bandages,  44 
Formalin  catgut,   sterilization  of, 

50 
Fowler's    ether   inhaler,     author's 
modification,  56 

Gastrectomy,    instruments     for, 

134 
Gastroenterostomy,      instruments 

for,  134 
Gastrostomy,     instruments      for, 

^33 


INDEX. 


165 


Gastrotomy,  instruments  for,  133 
Gauze,  36 

balsam  of  Peru,  39 

bandages,  43 

bichlorid  of  mercury,  38 

boric  acid,  38 

carbolized,  39 

cleansing  of,  43 

drains,  39 

iodoform,  No.  i,  36 
No.  2,  36 
No.  3,  38 
No.  4,  38 

Thiersch,  39 

zinc  oxid,  38 
Genitals,  preparation  of,  80 
Glass  basins,  disinfection  of,  15 

goods,  48 
Gloves,  rubber,  17,  28 
sterilization  of,  28 
Glycerin,  35 

Goiter,  instruments  for,   126 
Gowns,  28 

sterilization,  of  28 
Grafting,    skin-,   instruments   for, 

158 
Green  silk  protective,  47 
sterilization  of,  47 
Gut,  silkworm,  sterilization  of,  51 


Hand  basins,   disinfection  of,    14 

lotions,  27 

sponges,  42 
Hands,  after-care  of,  99 

disinfection  of,  98 
Harelip,  instruments  for,  122 
Head  bandage,  double  roller,   44 

position,  dependent,  83,  85 

preparation  of,  79 
Heart,  examination  of,  77 
Hemorrhage,  facial  expression  in, 

107 
Hemorrhoids,      instruments     for, 

152 
Hernia,  femoral,  instruments  for 

139 


Hernia,  inguinal,  instruments  for, 

137 
umbilical,  instruments  for,  137 
ventral,  instruments  for,  137 

Horsehair,  sterilization  of,  5 1 

Hydrocele,  instruments  for,  145 

Hydrogen  peroxid,  35 

Hvgiene,  general  rules  of,  in  after- 
treatment,  113 

Hypospadias,      instruments     for, 

145 
Hypostatic  pneumonia,  118 
Hysterectomy,    instruments    for, 

131 
vaginal,  instruments  for,  143 


IcHTHYOL,  35 

Ilecolostomy,  instruments  for,  133 
Impaction,    fecal,    in   after-treat- 
ment, 112 
Incision,  kidney  (closing),  instru- 
ments for,  149 
(for  exposing  kidney) ,  instru- 
ments for,  149 
laparotomy     (closing),    instru- 
ments for,  130 
(dressing),  articles  for,  130 
making,  instruments  for,  129 
(retraction),  instruments  for, 
129 
Infusion,      intravenous,      instru- 
ments for,  159 
Inguinal  colostomy,    instruments 
for,  133 
instruments  for,  137 
Inhaler,     ether,     preparation    of, 

56 
Instruments,  119 
and  supply  room,  23 
for  abdominal  cysts,  136 

drainage,  129 

operations,  128 
for  abscess,  157 
for  adenoids,  124 
for  amputation,  155 

of  breast,  127 


i66 


INDEX. 


Instruments   for    appendectomy, 

131 
for  bone  abscess,  158 
for  Cagsarian  section,  137 
for  cervical  adenectomy,  125 
for  cholecystectomy,    136 
for  cholecystenterostomy,  136 
for  cholecystostomy,  135 
for  circumcision,  144 
for  closing  laparotomy  incision, 

130 
for  colporrhaphy,  141 
for  colpotomy,  141 
for  craniectomy,  120 
for  curettage  of  uterus,    140 
for  cut  throat,   126 
for  deviated  septum,    124 
for  empyema,  127 
for  excision  of  trigeminus,  120 

of  upper  jaw,  120 
for   extirpation   of   rectum   by 

abdomino-perineal  route,  153 
for  extrauterine  pregnancy,  131 
for  femoral  hernia,  139 
for  fistula  in  ano,  151 
for  gastrectomy,  134 
for  gastroenterostomy,  134 
for  gastrostomy,  133 
for  gastrotomy,  133 
for  goiter,  126 
for  harelip,  122 
for  hemorrhoids,  152 
for  hydrocele,  145 
for  hypospadias,  145 
for  hysterectomy,  131 
for  ileocolostomy,  133 
for  inguinal  colostomy,  133 

hernia,  137 
for  internal  urethrotomy,   1 46 
for  intravenous  infusion,  159 
for  kidney    exploration,    150 

incision  (closing),  149 

(for  exposing  kidney),  149 

suspension,  150 
for  making  laparotomy  incision, 

129 
for  nephrectomy,  151 


Instruments  for  nephrotomy,  150 
for  occlusion  of  carotids,  126 
for  oophorectomy,  131 
for  opening  mastoid,  122 
for  operations  on  anus,  151 

on  rectum,    151 

on  scalp,    119 
for  perineal  section,  146 
in  stone  cases,   148 

section  without  a  guide  in 
impassable  stricture,  148 
for  perineorrhaphy,  142 
for  prolapse  of  rectum,    152 
for  prostatectomy,  148 
for  rectovaginal  fistula,  143 
for  removal  of    plaster-of- Paris 

cast,  159 
for  resection  of  intestine,  132 

of  joints,  154 

of  lower  jaw,  121 

of  rib,  127 
for  retracting    laparotomy  inci- 
sion, 129 
for  salpingo-oophorectoniy,  131 
for  skin-grafting,  158 
for  staphylorrhaphy,  123 
for  suprapubic  cystotomy,  148 
for  suturing  patella,  156 
for  tonsillotomy,  124 
for  trachelorrhaphy,  140 
for  tracheotomy,  125 
for  trephining,  120 
for  umbilical  hernia,  137 
for  uranoplasty,  123 
for  urethral  caruncle,  142 
for  vaginal   hysterectomy,    143 

operations,  139 
for  varicocele,  144 
for  varicose  veins,  157 
for  ventral  hernia,  137 
sterilization  of,  23 
Intestine,  large,  preparation  of,  81 
resection  of,  instruments  for,  132 
small,  preparation  of,  81 
Intra-abdominal  accessories,  129 
Intravenous       infusion,       instru- 
ments for,  159 


INDEX. 


167 


lodin  catgut,  sterilization    of,   51 

tincture  of,  34 
Iodoform  emulsion,  34 
gauze  No.  i,  36 
No.  2,  36 
No.  3,  38 
No.  4,  38 
mixture,  whale  oil  and,  35 
powder,  31 


Jaw,  lower,  resection    of,  instru- 
ments for,  121 
upper,  excision   of,  instruments 
for,  120 
Joints,    resection   of,  instruments 

for,  154 
Junior  nurse,  19 

second,  21 
Junker's   apparatus,  67 


Kangaroo     tendon,    sterilization 

of,  51 
Kelly  pads,  30 
Kidney,    examination   of,    77 

exploration,     instruments     for, 

150 
incision    (closing),    instruments 
for,  149 
(for  exposing  kidney),  instru- 
ments for,  149 
position,  91 
single,  93 
suspension,      instruments      for, 

150 
Knee-chest  position,  93,  94 


Lamb's  wool,  41 
Laparatomy  dressing,  43 

incision    (closing),  instruments 
for,  130 
(dressing),  articles  for,  130 
(making),     instruments     for, 
129 


Laparatomy  incision  (retraction), 
instruments  for,  129 
pads,  43 
sheets,  29 

sterilization  of,  29 
sponges,  42 
Ligature  material,  sterilization  of, 

48 
Lime,  chlorinated,  27 
Lime-water,  34 

Linen  thread,  sterilization  of,   51 
Lithotomy  position,  89,  91 
exaggerated,  90,  92 
with  sling  sheet,  90 
Lower   jaw,    resection  of,   instru- 
ments for,  121 
Lungs,  examination  of,  77 


Magnesia  sulphate,  32 

Masks,  27 

Mastoid,  opening   of,  instruments 

for,  122 
Mercury,  bichlorid  of,  32 

gauze  of,  38 
Mikulicz  drain,  41 
Mouth,  preparation  of,  79 
Muslin  bandages,  43 

bottle  bags,  31 

hand,  foot,  arm,  and  leg  bags, 
31 


Nail  cleaners,  26 

files,  26 

scissors,  26 
Neck  position,  extended,  83,  85 

preparation  of,  80 
Nephrectomy,     instruments     for, 

151 
Nephrotomy,  instruments  for,  150 
Nickel  work,  cleansing  of,  15 
Nitrous  oxid  and  ether    anesthe- 
sia, 66 
and  oxygen  anesthesia,  66 
anesthesia,  58 
Nose,  preparation  of,  81 


i68 


INDEX. 


Nurse,  17 

anesthetic,  21 

junior,  19 
second,  21 

senior,  18 
Nurses'  caps,  27 

costume,  15,  16 
ISj^utrition  in  after-treatment,  no 


Occlusion    of    carotids,    instru- 
ments for,  126 

Oil,  olive,  35 

whale,   and   iodoform  mixture, 

35 
Olive  oil,  35 
Oophorectomy,    instruments    for, 

131 
Opening     mastoid,      instruments 

for,  122 
Operating  room,  11 
costumes,  15 
disinfection  of,  14 
furniture,  12 

general  considerations,  1 1 
personnel  of,  15 
relation  to  adjoining  rooms, 

1 1 
rules,  1 1 

sinks,  preparation  of,  13 
training,   course  preliminary 
to  entering,  2 1 
staff,  15 

table,  preparation  of,  13 
Operations,      abdominal,     instru- 
ments for,  128 
after-treatment,  102.      See  also 

Afier-treatment. 
articles  required  for,  J19 
field  of,  final  preparation,  94 
on  anus,  instruments  for,  151 
on  rectum,  instruments  for,  151 
on  scalp,  instruments  for,  119 
vaginal,  instruments  for,  139 
Operator's  costume,  17 
Orderly,  22 

costume  for,  1 7 


Oxalic  acid  crystals,  31 
solution,  34 


Pads,  Kelly,  30 

laparotomy,  43 

rubber,  covers  for,  31 
Pails,     dressing,     disinfection    of, 

14 
Pain  in  after-treatment,   109 
Paper  dressing,  43 
Paraffin,  35 

paper,  46 

silk,  sterilization  of,  51 
Parotitis,  postoperative,   108 
Patella,  suturing  of,  instruments 

for,  156 
Patient,  76 

general  appearance  of,  in  after- 
treatment,  107 
preparation,  76 

position  of,  on  operating  table, 

84 
preparation    of,    local,    general 
directions,  78 
Patients'  caps,  27 
Perineal    section   in   stone    cases, 
instruments  for,  148 
instruments  for,   146 
without  a  guide  in  impassable 
stricture,  instruments  for, 
148 
sheets,  29 

sterilization  of,  29 
Perineorrhaphy,  instruments  for, 

142 
Peritonitis,    facial   expression   in, 

107 
Permanganate  of  potassium  solu- 
tion, 33 
Pharynx,  preparation  of,  81 
Pitchers,  disinfection  of,  14 
Plaster,  adhesive,  45 

bandages,  44 
Plaster-of- Paris  cast,  instruments 
for  removal  of,  159 
outfit,  158 


INDEX. 


169 


Pneumonia,   facial  expression  in, 
108 
hypostatic,  iiS 
Position,  dorsal.  87 

abdominal     binder     applied, 
100 
dressing  applied,  100 
arms     fastened     ready     for 

final  preparation,  95 
operation  suit,  82 
ready  for  operation,  97 
for  breast  amputation,  84,  86 
for  operations  upon  upper  ab- 
domen, 86 
for  thoracotomy,  85,  86 
head,  dependent,  83,  85 
kidney,  91 
single,  93 
knee-chest,  93,  94 
lithotomy,  89,  91 
exaggerated,  90,  92 
with  sling  sheet,  90 
neck,  extended,  83,  85 
of  patient   on  operating  table, 

84 
Sims',  91,  93 
Trendelenburg,  88 
reversed,  88,  89 
ventral,  92,  94 
Potash,  bichromate  of,  32 

solution,  bichromate  of,  34 
Potassium  permanganate  crystals, 

31 
solution,  permanganate    of,    33 

Powders,  3 1 

Pregnancy,    extrauterine,    instru- 
ments for,  131 

Prolapse  of  rectum,   instruments 
for,  152 

Prostatectomy,  instruments     for, 
148 

Protective,  green  silk,  47 
sterilization  of,  47 

Protectors,  29 
anus,  30 

sterilization  of,  30 
sterilization  of,    29 


Pulse,  postoperative,   117 

Pus  basins,   disinfection  of,    14 


Rectovaginal      fistula,      instru- 
ments for,  143 
Rectum,    extirpation    of,    by   ab- 
domino-perineal  route,  instru- 
ments for,  153 
operations  on,  instruments  for, 

151 

preparation  of,  80 

prolapse    of,    instruments    for, 
152 
Resection     of    intestine,     instru- 
ments for,  132 

of  joints,   instruments  for,    154 

of  lower  jaw,    instruments   for, 
121 

of  rib,  instruments  for,  127 
Respiration,  postoperative,     117 
Retention  of  urine,  postoperative, 

114 
Retractor  bandages,  44 
Reversed  Trendelenburg  position, 

88,  89 
Rib,  resection  of,  instruments  for, 

127 
Rubber  aprons,  27 

bandages,  47 

bolsters,  47 

dam,  sterilization  of,  47 

drainage  tubes,  47 

sterilization  of,  47 

gloves,  17,  28 

sterilization  of,  28 

goods,  47 

pads,  covers  for,  3 1 

sheeting,  30 

tissue  drains,  41 


Salicylic  acid,  3  2 

Saline  powders,  31 
solution,  normal,  33 

Salpingo-oophorectomy,      instru- 
ments for,  131 


I70 


INDEX. 


Sand  bags,  53 

Sapo  viridis,  26 

Scalp,  operations  on,  instruments 

for,  119 
Scissors,  nail,  26 
Screen  covers,  30 
Scrub-up  tray,  14 
Section,     Caesarian,    instruments 
for,  137 
perineal,  in  stone  cases,  instru- 
ments for,  148 
instruments  for,  146 
without  a  guide,  in   impass- 
able stricture,  instruments 
for,   148 
Senior  nurse,  18 
Septum,     deviated,     instruments 

for,  124 
Silk,  paraffin,   sterilization  of,   51 
protective,  green,  47 

sterilization  of,  47 
sterilization  of,  5 1 
Silkworm  gut,  sterilization  of,   5 1 
Silver  wire,  sterilization  of,  52 
Sims'  position,  91,  93 
Single  kidney  position,  93 
Sinks,  preparation  of,  13 
Skin,   cocain  anesthesia   of,    74 
Skin-grafting,     instruments     for, 

158 

preparation  of,  77 
Slings,  45 
Soap,  26 
Soda,  bicarbonate  of,  32 

carbonate  of,  32 
Sodium  bicarbonate,  35 

carbonate,  27 

chlorid,  32 
Solutions,  32 

percentage  table  of,   52 
Spinal  analgesia,  59,  70 

rules  for  making  injection,  7 1 
Splints,  S3 
Sponges,  41 

hand,  42 

laparotomy,  42 

stick,  42 


Staphylorrhaphy,  instruments  for, 

123 
Starch  bandages,  44 
Sterile  water,  35 
Sterilization  of  absorbent  cotton, 

41 
of  antiseptic  catgut   No.  i,    50 
No.  2,  50 
No.  3,  50 

of  anus  protectors,  30 

of  blankets,  30 

of  braided  catgut,  51 

of  brushes,  25 

of  catgut,  48 

of  chromic  catgut  No.  i,  49 
No.  2,  so 

of  formalin  catgut,  50 

of  gauze,  43 

of  gowns,  28 

of  green  silk  protective,  47 

of  hands,  98 

of  horsehair,  s  i 

of  instruments,  23 

of  iodin  catgut  No.  3,  S'^ 

of  kangaroo  tendon,  s  i 

of  laparotomy  sheets,  29 

of  ligature  material,  48 

of  linen  thread,  5 1 

of  nonabsorbent  cotton,  41 

of  paraffin  silk,  $1 

of  perineal  sheets,  29 

of  protectors,  29 

of  rubber  dam,  47 
drainage  tubes,  47 
gloves,  28 

of  silk,  s  I 

of  silkworm  gut,  51 

of  silver  wire,  S2 

of  suture  material,  48 

of  towels,  30 
Sterilizing  room,  40 
Stick  sponges,  42 
Stomach,  dilatation  of,  postopera- 
tive, 112 

preparation  of,  81 
Stone   cases,   perineal   section  in, 

instruments  for,  148 


INDEX. 


171 


Stricture,  impassable,  perineal 
section  without  a  guide  in,  in- 
struments for,  148 

Suprapubic  cystotomy,  instru- 
ments for,  148 

Surgeons'  caps,  27 

Suspension,  kidney,  instruments 
for,  150 

Suture  material,  sterilization  of, 
48 

Suturing  of  patella,  instruments 
for,  156 


Table,  operating,  preparation  of, 

13 
Tables,  disinfection  of,  15 
T-bandages,  44 

double,  45 
Temperature,   postoperative,    115 

wound,  normal,  116 
Tendon,     kangaroo,     sterilization 

of,  51 
Thermocautery,  52 
Thiersch  gauze,  39 

powders,  31 

solution,  ;};^ 
Thirst  after  operation,   109 

treatment,  log 
Thoracotomy  position,  85,  86 
Thorax,  preparation  of,  80 
Thread,  linen,  sterilization  of,  51 
Throat,  cut,  instruments  for,  126 
Tincture  of  iodin,  34 
Tonsillotomy,     instruments     for, 

124 
Tourniquets,  47 
Towels,  30 

sterilization  of,  30 
Trachelorrhaphy,  instruments  for, 

140 
Tracheotomy,     instruments     for, 

125 
Training,  operating  room,  course 

preliminary  to  entering,  2 1 
Trendelenburg  cannula,  68 

position,  88 


Trendelenburg  cannula  position 
reversed,  88,  89 

Trephining,  instruments  for,    120 

Triangular  bandages,   45 

Trigeminus,  excision  of,  instru- 
ments for,  120 


Umbilical    hernia,    instruments 
for,  137 

Upper  jaw,    excision    of,    instru- 
ments for,  120 

Uranoplasty,  instruments  for,  123 

Urethral     caruncle,     instruments 
for,  142 

Urethrotomy,      internal,      instru- 
ments for,  146 

Urinary   system,   preparation   of, 
81 

Urine  in  after-treatment,  113 
retention  of,  postoperative,  114 

Uterus,  curettage  of,  instruments 
for,  140 


Vagina,  preparation  of,  80 
Vaginal  accessories,  139 

hysterectomy,  instruments  for, 

143 
operations,      instruments      for, 

139 
Varicocele,   instruments   for,    144 
Varicose   veins,   instruments   for, 

157 
Vaseline,  35 
Veins,  varicose,  instruments  for, 

157 
Ventral   hernia,   instruments  for, 

137 
position,  92,  94 
Vesicovaginal  fistula,  instruments 

for,  143 
Visitor's  costumes,  17 
Vomiting,  anesthetic,  105 
character  of  vomit,  106 
persistent,  106 
treatment  of,  106 


172 


INDEX. 


Water,  sterile,  35 

Wax  paper,  46 

Whale  oil  and  iodoform,  mixture, 

35 
Wicking  drains,  39 
Wire,  silver,  sterilization  of,  52 
Woelfier's  solution,  34 


Wool,  lamb's,  41 

Wound  temperature,  normal,  116 


Zinc  oxid  gauze,  38 
powder,  3  i 
solution,  chlorid  of,  34 


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Gynecologist  to  the  Presbyterian  Hospital,  Chicago.  Handsome  octavo 
volume  of  767  pages,  beautifully  illustrated,  including  many  in  colors. 
Cloth,  ;^5.00  net;  Sheep  or  Half  Morocco,  ^6.00  net. 

RECENTLY   ISSUED— BEAUTIFULLY   ILLUSTRATED 

This  entirely  new  work  is  written  for  the  student  of  obstetrics  as  well  as  for 
the  active  practitioner.  The  anatomic  changes  accompanying  pregnancy,  labor, 
and  the  puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text- 
book on  the  subject.  The  exposition  of  these  sections  is  based  mainly  upon 
studies  of  frozen  specimens,  in  which  department  the  author  has  had  a  larger 
experience  than  any  other  worker.  Unusual  consideration  is  given  to  embryo- 
logic  and  physiologic  data  of  importance  in  their  relation  to  obstetrics.  Great 
care  was  taken  in  the  selection  of  the  illustrations,  aiming  to  meet  the  varied  re- 
quirements of  both  the  undergraduate  and  the  practising  physician.  The  book 
expresses  the  most  advanced  thought  of  the  day. 


OPINIONS  OF  THE   MEDICAL  PRESS 


Medical  Record,  New  York 

"  The  author's  remarks  on  asepsis  and  antisepsis  are  admirable,  the  chapter  on  eclampsia 
is  full  of  good  material,  and  .  .  .  the  book  can  be  cordially  recommended  as  a  safe  guide." 

Buffalo  Medical  Journal 

"  As  a  practical  text-book  on  obstetrics  for  both  student  and  practitioner,  there  is  left  very 
little  to  be  desired,  it  being  as  near  perfection  as  any  compact  work  that  has  been  published." 

Dublin  Journal  of  Medical  Science 

"  Both  to  the  student  .  .  .  and  to  the  practitioner  who  requires  the  latest  opinion  on  any 
point  of  practice,  Dr.  Webster's  book  will  be  of  the  greatest  value." 


SAUNDERS'    BOOKS   ON 


GET  i^ •  THE  NEW 

THE  BEST  /\  m  6  r  1  C  2i  n  standard 

Illustrated   Dictionary 

Third  Revised  £dition — Recently  Issued 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches;  with  over  lOO  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Borland,  M.  D.,  Editor  of  "The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  800  pages,  bound  in  full  flexible  leather. 
Price,  ;^4.50  net;  with  thumb  index,  ;^5.oo  net. 

Gives  a  Maximum  Amount  of  Matter  in  a  Minimum  Space,  and  at  the  Lowest 

Possible  Cost 

THREE  EDITIONS  IN  THREE  YEARS— WITH  15OO  NEW  TERMS 

The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  i  % 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  fifteen  hundred 
new  terms  that  have  appeared  in  recent  medical  literature  have  been  added,  thus 
bringing  the  book  absolutely  up  to  date.  The  book  contains  hundreds  of  terms 
not  to  be  found  in  any  other  dictionary,  over  100  original  tables,  and  many  hand- 
some illustrations,  a  number  in  colors. 


PERSONAL   OPINIONS 


Howard  A.  Kelly.  M.  D.. 

Professor  of  Gynecology,  Johns  Hopkins  University ,  Baltimore. 

"  Dr.  Borland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
sire.     No  errors  have  been  found  in  my  use  of  it." 

Roswell  Park.  M.  D., 

Professor  of  Principles  and  Practice  of  Surgery  and  of  Clinical  Surgery,  University  of 
Buffalo. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within  rela- 
tively small  space.  I  find  nothing  to  criticize,  very  much  to  commend,  and  was  interested  in 
finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." 


GYNECOLOGY  AND    OBSTETRICS. 


The  American 
Text-Book  of  Obstetrics 

Second  Edition,  Thoroughly  Revised  and  Enlarged 


The  American  Text=Book  of  Obstetrics.  In  two  volumes.  Edited 
by  Richard  C.  Norris,  M.D.,  Assistant  Professor  of  Obstetrics  in  the 
University  of  Pennsylvania;  Art  Editor,  Robert  L.  Dickinson,  M.D,, 
Assistant  Obstetrician,  Long  Island  College  Hospital,  N.  Y.  Two 
handsome  octavo  volumes  of  about  600  pages  each;  nearly  900  illus- 
trations, including  49  colored  and  half-tone  plates.  Per  volume : 
Cloth,  ;^3.50  net;  Sheep  or  Half  Morocco,  ^4.00  net. 

RECENTLY   ISSUED— IN   TWO  VOLUMES 

Since  the  appearance  of  the  first  edition  of  this  work  many  important  advances 
have  been  made  in  the  science  and  art  of  obstetrics.  The  resuks  of  bacteriologic 
and  of  chemicobiologic  research  as  appUed  to  the  pathology  of  midwifery  ;  the  wider 
range  of  the  surgery  of  pregnancy,  labor,  and  of  the  puerperal  period,  embrace 
new  problems  in  obstetrics.  In  this  new  edition,  therefore,  a  thorough  and  critical 
revision  was  required,  some  of  the  chapters  being  entirely  rewritten,  and  others 
brought  up  to  date  by  careful  scrutiny.  A  number  of  new  illustrations  have  been 
added,  and  some  that  appeared  in  the  first  edition  have  been  replaced  by  others 
of  greater  excellence.  By  reason  of  these  extensive  additions  the  new  edition 
has  been  presented  in  two  volumes,  in  order  to  facilitate  ease  in  handling.  The 
pnce,  however,  remains  unchanged. 


PERSONAL  AND  PRESS  OPINIONS 


Alex.  J.  C.  Skene.  M.  D., 

Late  Professor  of  Gynecology,  Long  Island  College  Hospital,  Brooklyn. 
"  Permit  me  to  say  that  '  The  American  Text-Book  of  Obstetrics  '  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.     I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers." 

Matthew  D.  Mann.  M.  D., 

Professor  of  Obstetrics  and  Gynecology  in  the  University  of  Buffalo. 

"  I  like   it  exceedingly  and  have   recommended   the  first  volume  as  a  text-book  for  out 
sophomore  class.     It  is  certainly  a  most  excellent  work.     I  know  of  none  better." 

Americeoi  Joum&l  of  the  Medical  Sciences 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  practi- 
tioner, we  commend  it  because  we  believe  there  is  no  better." 


SAUNDERS'    BOOKS   ON 


Penrose's 
Diseases  of  Women 

Fifth  Revised  Edition 


A  Text=Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  550  pages,  with  225  fine  original  illustrations.     Cloth, 

;^3-75  net. 

RECENTLY   ISSUED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted,  and  the  main  points  are  made  clear  by  excellent  illustra- 
tions. The  new  edition  has  been  carefully  revised,  much  new  matter  has  been 
added,  and  a  number  of  new  original  illustrations  have  been  introduced.  In  its 
revised  form  this  volume  continues  to  be  an  admirable  exposition  of  the  present 
status  of  gynecologic  practice. 


PERSONAL  AND  PRESS  OPINIONS 


Howard  A.  Kelly.  M.  D.. 

Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University ,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women'  received.     I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." 

E.  E.  Montgomery,  M.  D., 

Professor  of  Gynecology,  Jefferson  Medical  College,  Philadelphia. 
"  The  copy  of '  A  Text-Book  of  Diseases  of  Women  '  by  Penrose,  received  to-day.     I  have 
looked  over  it  and  admire  it  very  much.     I  have  no  doubt  it  will  have  a  large  sale,  as  it  justly 
merits." 

Bristol  Medico-Chirurgic&l  Journal 

"  This  is  an  excellent  work  which  goes  straight  to  the  mark.  .  .  .  The  book  may  be  taken 
as  a  trustworthy  exposition  of  modern  gynecology." 


GYNECOLOGY  AND    OBSTETRICS. 


Garrigues* 
Diseases  of  Women 

Third  Edition,  Thoroughly  Revised 


A  Text-Book  of  Diseases  of  Women.  By  Henry  J.  Garrigues, 
A.  M.,  M.  D.,  Gynecologist  to  St.  Mark's  Hospital  and  to  the  German 
Dispensary,  New  York  City.  Handsome  octavo,  756  pages,  with  367 
engravings  and  colored  plates.  Cloth,  ;^4.50  net ;  Sheep  or  Half 
Morocco,  ;^5.5o  net. 

INCLUDING  EMBRYOLOGY  AND   ANATOMY   OF  THE  GENITALIA 

The  first  two  editions  of  this  work  met  with  a  most  appreciative  reception  by 
the  medical  profession  both  in  this  country  and  abroad.  In  this  edition  '.he  entire 
work  has  been  carefully  and  thoroughly  revised,  and  considerable  new  matter 
added,  bringing  the  work  precisely  down  to  date.  Many  new  illustrations  have  been 
introduced,  thus  greatly  increasing  the  value  of  the  book  both  as  a  text-book  and 
book  of  reference.  In  fact,  the  illustrations  form  a  complete  atlas  of  the  embry- 
ology and  anatomy  of  the  female  genitalia,  besides  portraying  most  accurately 
numerous  pathologic  conditions  and  the  various  steps  in  the  gynecologic  opera- 
tions detailed.  The  work  is,  throughout,  practical,  theoretical  discussions  being 
carefully  avoided. 


PERSONAL  AND   PRESS  OPINIONS 


Thad.  A.  Reamy,  M.  D. 

Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 
"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in  the 
English  language  ;    it  is  condensed,  clear,  and  comprehensive.     The  profound   learning  and 
great  clinical  experience  of  the   distinguished  author  find  expression  in  this  book  in  a  most 
attractive  and  instructive  form." 

Bache  Emmet,  M.  D. 

Professor  of  Gynecology  in  the  New  York  Post-Gradtiate  Medical  School. 
"  I  think  that  the  profession  at  large  owes  you  gratitude  for  having  given  to  the  medical 
world  so  valuable  a  treatise.     I  shall  certainly  put  it  forward  to  my  classes  as  one  of  the  best 
guides  with  which  I  am  familiar,  not  only  with  which  to  study,  but  for  constant  consultations." 

American  Journal  of  the  Medical  Sciences 

"It  reflects  the  large  experience  of  the  author,  both  as  a  clinician  and  a  teacher,  and  com- 
prehends much  not  ordinarily  found  in  text-books  on  gynecology.  The  book  is  one  of  the 
most  complete  treatises  on  gynecology  that  we  have,  dealing  broadly  with  all  phases  of  the 
subject." 


SAUNDERS'    BOOKS    ON 


Saunders*  Year-Book 

The  American  Year=Book  of  Medicine  and  Surgery.  A  Yearly- 
Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all  branches 
of  Medicine  and  Surgery.  Arranged  with  critical  editorial  comments 
by  eminent  American  specialists,  under  the  editorial  charge  of  George 
M.  Gould,  M.  D.  Vol.  I.,  General  Medicine ;  Vol.  II.,  General  Surgery 
Per  volume:  Cloth,  ^$3.00  net;  Half  Morocco,  ^3.75  net.  Sold  by 
Subscription. 

EQUIVALENT  TO  A  POST  GRADUATE  COURSE 

The  contents  of  these  volumes,  critically  selected  from  leading  journals,  mono- 
graphs, and  text-books,  is  much  more  than  a  compilation  of  data.  The  extracts 
are  carefully  edited  and  commented  upon  by  eminent  specialists,  the  reader  thus 
obtaining  also  the  invaluable  annotations  and  criticisms  of  the  editors. 

The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commea- 
taries  and  expositions  .  .  .  proceeding  from  writers  fully  qualified  to  perform  these  tasks." 


Barton  and  Well^* 
Medical  Thesaurus 


A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  M.  D.,  Assistant  to  Professor  of  Materia  Medica  and  Thera- 
peutics, Georgetown  University,  Washington,  D.  C. ;  and  Walter  A. 
Wells,  M.  D.,  Demonstrator  of  Laryngology,  Georgetown  University, 
Washington,  D.  C.  i2mo  of  534  pages.  Flexible  leather,  ^^2.50  net  ; 
with  thumb  index,  ^3.00  net. 

A  UNIQUE  WORK— RECENTLY  ISSUED 

This  work  is  just  the  opposite  of  a  dictionary  :  when  the  idea  or  meaning  is 
in  the  mind,  it  endeavors  to  supply  the  word  or  phrase  to  express  that  idea.  Its 
value  is  evident. 

Boston  Medical  and  Surgical  Journal 

"We  can  easily  see  the  value  of  such  a  book,  and  can  certainly  recommend  it  to  our 
readers." 


GYNECOLOGY  AND    OBSTETRICS.  ii 

American 
Text-Book  of  Gynecology 

Second  Edition,  Thoroughly  Revised 


American  Text-Book  of  Gynecology :  Medical  and  Surgical. 
By  lO  of  the  leading  Gynecologists  of  America.  Edited  by  J.  M. 
Baldy,  M.  D.,  Professor  of  Gynecology  in  the  Philadelphia  Polyclinic. 
Handsome  imperial  octavo  volume  of  718  pages,  with  341  illustrations 
in  the  text,  and  38  colored  and  half-tone  plates.  Cloth,  ;^6.oo  net; 
Sheep  or  Half  Morocco,  ^7.00  net. 

MEDICAL  AND  SURGICAL 

This  volume  is  thoroughly  practical  in  its  teachings,  and  is  intended  to  be  a 
working  text-book  for  physicians  and  students.  Many  of  the  most  important 
subjects  are  considered  from  an  entirely  new  standpoint,  and  are  grouped  together 
in  a  manner  somewhat  foreign  to  the  accepted  custom.  In  the  revised  edition 
of  this  book  much  new  material  has  been  added  and  some  of  the  old  eliminated 
or  modified.  More  than  forty  of  the  old  illustrations  have  been  replaced  by  new 
ones.  The  portions  devoted  to  plastic  work  have  been  so  greatly  improved  as 
to  be  practically  new.  Hysterectomy,  both  abdominal  and  vaginal,  has  been 
rewritten,  and  all  the  descriptions  of  operative  procedures  have  been  carefully 
revised  and  fully  illustrated. 


OPINIONS  OF  THE   MEDICAL  PRESS 


The  Lancet,  London 

"  Contains  a  large  amount  of  information  upon  special  points  in  the  technique  of  gyne- 
cological operations  which  is  not  to  be  found  in  the  ordinary  text-book  of  gynecology." 

British  Medical  Journal 

"The  nature  of  the  text  may  be  judged  from  its  authorship;  the  distinguished  authorities 
who  have  compiled  this  publication  have  done  their  work  well.  This  addition  to  medical 
literature  deserves  favorable  comment." 

Boston  Medical  zoid  Surgical  Journal 

"  The  most  complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have 
been  neglected  .  .  .  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has 
any  desire  to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illus- 
trations and  plates  the  book  surpasses  anything  we  have  seen." 


12  SAUNDERS'    BOOKS   ON 

Dorland*s 
Modern   Obstetrics 


Modern  Obstetrics :  General  and  Operative.     By  W.  A.  Newman 

Borland,  A.  M.,  M.  D.,  Assistant  Instructor  in  Obstetrics,  Univer- 
sity of  Pennsylvania ;  Associate  in  Gynecology  in  the  Philadelphia 
Polyclinic.  Handsome  octavo  volume  of  797  pages,  with  201  illustra- 
tions.    Cloth,  ^4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 
Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

Journal  of  the  American  Medical  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.    By  Edward  P.  Davis,  A.  M., 
M.  D.,   Professor   of  Obstetrics    in   the   Jefferson  Medical   College  and 
Philadelphia   Polyclinic ;    Obstetrician    and    Gynecologist,   Philadelphia 
Hospital.     i2mo  of  400  pages,  illustrated.     Buckram,  $i.7S  riet. 
RECENTLY  ISSUED— SECOND  REVISED  EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  pregnancy,  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instruction 
and  training.  This  volume  presents  this  information  in  the  most  convenient 
form.  This  second  edition  has  been  very  carefully  revised  throughout,  bringing 
the  subject  down  to  date. 

The  Lancet,  London 

"  Not  onlv  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS.  13 

Schaffer  and  Edgar's 

Labor  and  Operative  Obstetrics 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics.     By  Dr. 

O.  Schaffer,  of  Heidelberg.  From  the  Fifth  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medi- 
cal School,  New  York.  With  14  lithographic  plates  in  colors,  139  other 
illustrations,  and  1 1 1  pages  of  text.  Cloth,  ^2.00  net.  In  Saunders^ 
Hand-Atlas  Series. 

This  book  presents  the  act  of  parturition  and  the  various  obstetric  operations 
in  a  series  of  easily  understood  illustrations,  accompanied  by  a  text  treating  the 
subject  from  a  practical  standpoint.  The  author  has  added  many  accurate  repre- 
sentations of  manipulations  and  conditions  never  before  clearly  illustrated. 

American  Medicine 

"  The  method  of  presenting  obstetric  operations  is  adinirable.  The  drawings,  reprt^senting 
original  work,  have  the  commendable  merit  of  illustrating  instead  of  confusing.  It  would  be 
difficult  to  find  one  hundred  pages  in  better  form  or  containing  more  practical  points  for 
students  or  practitioners." 

Schaffer  and  Edg(ar*s 

Obstetric  Diag'nosis  and  Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treatment.     By 

Dr.  O.  Schaffer,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School, 
N.  Y.  With  122  colored  figures  on  56  plates,  38  text-cuts,  and  315 
pages  of  text.     Cloth,  ^3.00  net.     In  Saundej-s'  Hand-Atlas  Series. 

This  book  treats  particularly  of  obstetric  operations,  and,  besides  the  wealth 
of  beautiful  lithographic  illustrations,  contains  an  extensive  text  of  great  value. 
This  text  deals  with  the  practical,  clinical  side  of  the  subject.  The  symptoma- 
tology and  diagnosis  are  discussed  with  all  necessary  fullness,  and  the  indications 
for  treatment  are  definite  and  complete. 

New  York  Medical  Journal 

"The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the  text 
can  safely  be  commended,  not  only  as  elucidatory  of  the  plates,  but  as  expounding  the  scien- 
tific midwifery  of  to-day." 


14  SAUNDERS'   BOOKS   ON 

Schaffer  and  Norris* 
Gynecolo^ 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of 
Heidelberg.  From  the  Second  Revised  and  Enlarged  German  Edition. 
Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gynecolo- 
gist to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text. 
Cloth,  ;^3.50  net.     In  Saunders'  Hand- Atlas  Series. 

The  value  of  this  atlas  to  the  medical  student  and  to  the  general  practitioner 
will  be  found  not  only  in  the  concise  explanatory  text,  but  especially  in  the  illus- 
trations. The  large  number  of  colored  plates,  reproducing  the  appearance  of 
fresh  specimens,  give  an  accurate  mental  picture  and  a  knowledge  of  the  changes 
induced  by  disease  of  the  pelvic  organs  that  cannot  be  obtained  from  mere 
description. 

American  Journal  of  the  Medical  Sciences 

"  Of  the  illustrations  it  is  difficult  to  speak  in  too  high  terms  of  approval.  They  are  so 
clear  and  true  to  nature  that  the  accompanying  explanations  are  almost  superfluous.  We 
commend  it  most  earnestly." 

Galbraith's 
Four  Epochs  of  Woman's  Life 

Second  Revised  Edition — Recently  Issued 


The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.     By 

Anna  M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of 
Medicine,  etc.  With  an  Introductory  Note  by  John  H.  Musser, 
M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 
i2mo  of  247  pages.     Cloth,  ^1.50  net. 

MAIDENHOOD,    MARRIAGE.    MATERNITY.   MENOPAUSE 

In  this  instructive  work  are  stated,  in  a  modest,  pleasing,  and  conclusive  manner, 
those  truths  of  which  every  woman  should  have  a  thorough  knowledge.  Written, 
as  it  is,  for  the  laity,  the  subject  is  discussed  in  language  readily  grasped  even  by 
those  most  unfamiliar  with  medical  subjects. 

Birmingham  Medical  Review.  En{(land 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public.  But 
we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  wholesome." 


G YNECOLOG V  AND    OBSTETRICS.  1 5 

Schaffer  and  Webster's 
Operative  Gynecology 


Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaf- 
fer, of  Heidelberg.  Edited,  with  additions,  by  J.  Clarence  Webster, 
M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gynecology  in 
Rush  Medical  College,  in  affiliation  with  the  University  of  Chicago. 
42  colored  lithographic  plates,  many  text-cuts,  a  number  in  colors,  and 
138  pages  of  text.     In  Saunders'  Hand- Atlas  Series.    Cloth,  $3.00  net. 

RECENTLY  ISSUED 

Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and  the 
hthographer  in  the  preparation  of  the  plates  of  this  atlas.  They  are  based  on 
hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully  the 
various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demonstrating 
by  illustrations. 

Medical  Record,  New  York 

"  The  volume  should  prove  most  helpful  to  students  and  others  in  grasping  details  usually 
to  be  acquired  only  in  the  amphitheater  itself." 

De  Lee's 
Obstetrics  for  Nurses 


Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor  of 
Obstetrics  in  the  Northwestern  University  Medical  School ;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.     i2mo  volume  of  460  pages, 

fully  illustrated.  Cloth,  $2.50  net. 

RECENTLY  ISSUED 

While  Dr.  De  Lee  has  written  his  work  especially  for  nurses,  yet  the  prac- 
titioner will  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often  devolve 
upon  him  in  the  early  years  of  his  practice.  The  illustrations  are  nearly  all 
original,  and  represent  photographs  taken  from  actual  scenes.  The  text  is  the 
result  of  the  author's  eight  years'  experience  in  lecturing  to  the  nurses  of  five 
different  training  schools. 

J.  Clifton  Ed£(ar.  M.  D., 

Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University ,  New  York. 
"  It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 


I6     SAUNDERS-  BOOKS  ON  GYNECOLOGY  AND  OBSTETRICS. 

American  Pocket  Dictionary  '"'^cenStuS''"'' 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Borland,  A.M.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  American 
Academy  of  Medicine.  Over  550  pages.  Full  leather,  limp,  with 
gold  edges.     ^1.00  net;  with  patent  thumb  index,  1^1.25  net. 

James  W.  Holland.  M.  D., 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  fefferson  Medical  College 

Philadelphia. 
"  I  am  struck  at  once  with  admiration  at  the   compact  size  and  attractive   exterior.     I 
can  recommend  it  to  our  students  without  reserve." 

Cra^in's    GyneCOlOg(y.  New  (6th)  Edition 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  M.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  215  pages,  62  illustrations.  Cloth,  ^i.oo 
net.     In  Saunders''   Question- Co^npend  Serie''. 

The  Medical  Record,  New  York 

"  A  handy  volume  and  a  distinct  improvement  <i'  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  hus  done." 

Boisliniere's   Obstetric   Accidents,   Einer|(encies,   and 
Operations 

Obstetric  Accidents,  Emergencies,  and  Operations.  By 
the  late  L.  Ch.  Boisliniere,  M.  D,,  Emeritus  Professor  of  Ob- 
stetrics, St.  Louis  Medical  College  ;  Consulting  Physician,  St.  Louis 
Female  Hospital.      381  pages,  illustrated.     Cloth,  ^2.00  net. 

British  Medical  Journal 

"  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience.    Its  merit  lies  in  the  judgment  which  comes  from  experience." 

AshtOn'S    Obstetrics.  J"st  issued— New  (6th)  Edition 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Crown  octavo,  256  pages,  75  illustrations.  Cloth,  ;^i.oo 
net.     In  Saunders'  Question- Compend  Series. 

Southern  Practitioner 

"An  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admir- 
able compend,  and  the  best  condensation  we  have  seen." 


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